Faculty Bibliography

Background: To bolster medical student wellbeing and combat burnout, the NYU School of Medicine (NYUSOM) implemented a longitudinal resiliency curriculum coupled with a wellbeing self-assessment tool. We qualitatively studied the impact of this curriculum on knowledge, self-awareness, and behaviors related to wellbeing and resiliency.
Method(s): The MD AWARE curriculum was launched in August 2017 for the NYUSOM class of 2020. Six sessions were implemented at critical junctions of their training. Each session includes a short lecture, followed by a small group activity led by trained facilitators. At the start of each session, students complete an anonymous online self-assessment adapted from three validated assessment tools measuring different aspects of wellbeing and burnout. Students immediately receive scores with explanations and benchmarks of each and then debrief in their small group. After each MD AWARE session, students completed a retrospective pre/post evaluation survey. Focus Groups (FG) were held in December 2017 (after Sessions 1& 2) to gain richer insight into the impact of the curriculum and self-assessment tool. A purposeful sampling strategy with maximal variation was employed to recruit participants; 10 students participated in each FG. Qualitative data was gathered through the surveys and the FG. The FG were recorded and transcribed. Each FG had 2 project staff members and post-session debriefing. Member-checking was also used. Responses were subsequently coded and analyzed by two experienced faculty members (a third colleague assisted in theme triangulation). An iterative data analysis strategy was applied. Throughout the analysis, an audit trail, frequent memo writing and a reflexivity journal was maintained.
Result(s): Themes: Community Building: Connecting with another student it was helpful for my wellbeing Skill and Knowledge Acquisition and Application: The main sort of takeaway is you need to be aware of (Burnout) and if you need help there are resources Importance of Faculty Development: I think that a prep session between those who designed the curriculum and those who facilitate the small-groups could go a long way towards creating the environment I imagine was originally intended Value of Refection: The score didn't add much It was more about the act of answering the questions than the number that came out of it NYU Administration Values Medical Student Wellbeing: Just the fact that NYU has this program and is making it part of orientation already speaks volumes about its priorities: that we matter
Conclusion(s): Thematic analysis of the impact of MD AWARE indicated that it provides concrete information on resources available to the students. Additionally, the students value both protected time with their peers and for self-refection. Lastly, although care must to be taken in selecting faculty to facilitate the small groups, the mere existence of the longitudinal curriculum signaled that the NYUSOM administration values medical student wellbeing

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

Background: Discharge to skilled nursing facilities (SNF) is common in patients with heart failure (HF). The goal of a SNF stay is to improve functional status to allow patients to return home safely. However, the second transition from SNF to home may also be risky. Here, we examine the association between receipt of home health care (HHC) and readmission risk among patients discharged from SNF to home following HF hospitalization.
Method(s): We examined all Medicare fee-for-service beneficiaries 65 and older admitted 2012-2015 with a HF diagnosis discharged to SNF then subsequently discharged home. The primary outcome was unplanned read-mission within 30 days of SNF to home discharge, using CMS's HF read-mission methodology. We plotted time to readmission with Kaplan-Meier curves and compared these groups with a log-rank test. Then, we compared time to readmission using an adjusted Cox model; this model included a frailty term to account for correlation of patient outcome by SNF.
Result(s): There were 67,585 HF hospitalizations discharged to SNF and subsequently discharged home; 13,257 (19.6%) were discharged with HHC, 54,328 (80.4%) without. Patients discharged home from SNF with HHC had lower 30-day readmission rates than patients discharged without HHC (22.8% vs 24.5%, p< 0.0001). Kaplan-Meier curves demonstrated that patients discharged home from SNF with HHC have a longer unadjusted time to readmission. Of those readmitted within 30 days, median time to readmission for those discharged home from SNF with HHC was 11 days and 9 days for those discharged home without HHC (p< 0.0001). After risk-adjustment, patients discharged home with HHC still had a lower hazard of 30-day readmission.
Conclusion(s): Patients who received HHC were less likely to be readmitted within 30 days compared to those discharged home without HHC. This is unexpected as patients discharged with HHC likely have more functional impairments and therefore at higher readmission risk. Since patients requiring a SNF stay after hospital discharge may have additional needs, they may be especially likely to benefit from restorative therapy through HHC; however only about 20% received such services

Assessment and evaluation of trainees' clinical performance measures is needed to ensure safe, high-quality patient care. These measures also aid in the development of reflective, high-performing clinicians and hold graduate medical education (GME) accountable to the public. While clinical performance measures hold great potential, challenges of defining, extracting, and measuring clinical performance in this way hinder their use for educational and quality improvement purposes. This article provides a way forward by identifying and articulating how clinical performance measures can be used to enhance GME by linking educational objectives with relevant clinical outcomes. The authors explore four key challenges: defining as well as measuring clinical performance measures, using electronic health record and clinical registry data to capture clinical performance, and bridging silos of medical education and health care quality improvement. The authors also propose solutions to showcase the value of clinical performance measures and conclude with a research and implementation agenda. Developing a common taxonomy of uniform specialty-specific clinical performance measures, linking these measures to large-scale GME databases, and applying both quantitative and qualitative methods to create a rich understanding of how GME affects quality of care and patient outcomes is important, the authors argue. The focus of this article is primarily GME, yet similar challenges and solutions will be applicable to other areas of medical and health professions education as well.

Statement of Problem Or Question (One Sentence): Can a home visit complex care management program successfully identify and engage high risk patients in a FQHC? Objectives of Program/Intervention (No More Than Three Objectives): 1. Identify patients at an FQHC who are at risk for preventable hospitalization 2. Enroll and engage patients in a home visit based complex care management program. Description of Program/Intervention, Including Organizational Context (E.G. Inpatient Vs. Outpatient, Practice or Community Characteristics): The Primary Care Plus program (PCP+) is a home visit based program established to address the needs of patients at risk for preventable hospitalizations within the Family Health Centers at NYU Langone. The program staff-a physician, a nurse practitioner, a social worker and 2 community health workers-coordinate as a team to identify and address the biopsychosocial needs of high risk patients. A key intervention is the home visit lead by a physician or nurse practitioner to perform the medical assessment, medication reconciliation, and identification of both medical and social impediments to optimal health. The program is not intended to replace the patient's primary care provider, but to function as an addition to the patient's care team, identifying and mitigating risk drivers, and handing off to the primary team and care management resources once the risk drivers have been addressed. Patients are referred into the program by either their primary care doctors or care management. The program is restricted to those patients who have a continuity relationship in the Federally Qualified Health Center, and who are identified as being at risk for a preventable hospitalization. Latitude is given to the referral source in how patients are identified; guidance is given to focus on patients with a history of preventable hospitalizations (as defined by PQI) or patients with advanced disease and potential palliative care needs. Measures of Success (Discuss Qualitative And/Or Quantitative Metrics Which Will Be Used To Evaluate Program/Intervention): The primary measure of success is patient engagement. Patient engagement is defined by both consent to the program and successful home visit by the medical provider. Other outcome metrics are patient characteristics, number of emergency department visits and number of inpatient hospitalizations in the 12 months before program enrollment. Findings To Date (It Is Not Sufficient To State Findings Will Be Discussed): Since program inception in August 2018 through December 31, 2018, 75 patients have been identified by care management or primary care providers as potential candidates for the program and who met criteria as defined above. Of the 75 patients, 6 (8%) declined the program, and another 10 (13.3%) could not be found. The remaining 59 patients were seen at home and assessed. Total engagement was 78.7%. Patients identified represent a cohort of patients with an average of 2.0 inpatient admissions and 3.2 emergency department visits in the preceding 12 months prior to enrollment. Key Lessons For Dissemination (What Can Others Take Away For Implementation To Their Practice Or Community?): Identification of a high-risk patient population in a federally qualified health center and referral into a home visit based care management program is associated with high acceptance and engagement. Future study will determine if patients enrolled in the program have an impact on risk drivers and preventable hospitalizations

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.

BACKGROUND AND PURPOSE/OBJECTIVE:Patients with ischemic stroke of cardioembolic origin are at risk of visceral (renal or splenic) infarction. We hypothesized that serum troponin level at time of ischemic stroke would be associated with presence of visceral infarction. METHODS:Data were abstracted from a single center prospective stroke database over 18 months and included all patients with ischemic stroke who underwent contrast-enhanced computerized tomography (CT) of the abdomen and pelvis for clinical purposes within 1 year of stroke. The primary predictor was troponin concentration ≥.1 ng/mL. The primary outcome was visceral infarct (renal and/or splenic) on CT abdomen and pelvis. Univariate and multivariable logistic regression models were used to estimate the odds ratio and 95% confidence intervals (OR, 95% CI) for the association of troponin with visceral infarction. RESULTS:Of 1233 patients with ischemic stroke, 259 patients had a qualifying visceral CT. Serum troponin level on admission was measured in 237 of 259 patients (93.3%) and 41 of 237 (17.3%) had positive troponin. There were 25 patients with visceral infarcts: 16 renal, 7 splenic, and 2 both. In univariate models, patients with a positive troponin level (versus negative) were more likely to have visceral infarcts (39.1% [9/23] versus 15.0% [32/214], P = .008) and this association persisted in multivariable models (adjusted OR 3.83; 95% CI 1.42-10.31, P = .006). CONCLUSIONS:In ischemic stroke patients, elevated serum troponin levels may help identify patients with visceral infarcts. This suggests that troponin in the acute stroke setting is a biomarker of embolic risk. Larger studies with systematic visceral imaging are needed to confirm our findings.

Background: Faculty development programs (FDP) in medical education can increase clinician educators' (CE) confidence in teaching and improve their teaching skills. The impact of FDP on faculty's role as educators and sense of an educator community is less well understood. Identification with a community of educators (COE) can enhance teaching in the workplace along with personal and professional growth. We evaluated the impact of participation in the Education for Educators program (E4E) on these issues. E4E is a yearlong FDP designed to enhance teaching confidence and skill in a variety of venues; improve ability to assess learners; promote an environment of academic inquiry with trainees at different levels; and create a COE.
Method(s): An annual needs assessment of key stakeholders including medical school deans, program directors, and participants forms the basis for the E4E curriculum. The program begins with a Group Observed Structured Teaching Experience (GOSTE) followed by three 3-hour workshops which pair a clinical and teaching topic. After each workshop, participants complete " commitment to change" statements and take part in peer-to-peer (P2P) observations wherein participants observe each other teaching in their usual teaching environment. The program concludes with structured debriefs and an assessment of participants' perception of their role as educators and their sense of an educator community. Participants reported how participation in E4E impacted their teaching and what new skills they implemented. Structured phone conversations assessed the same information one-year after completing the program.
Result(s): Fifty-one CEs completed the program in two cohorts (2016-17 and 2017-18), 60% of whom were women. Participants included 20 hospitalists and 31 subspecialists, averaging 8 years in practice (range 1-28) and spending an average of 63% of their time in patient care (range 10-100%). Thirty-eight participants (75%) completed the immediate post-program debrief sessions. Participants reported a renewed identification with their role as an educator. They cited a change in perspective to become more reflective and focused on teaching and recognized that their teaching skills can in fact be improved. Many reported time constraints as a barrier to teaching. They noted an increased identification with their COE, stating that they now had peers and mentors with whom to discuss teaching challenges. To date, phone interviews have been completed with three participants at one-year of follow-up. The preliminary Results show a sustained impact on educators' roles and belonging to a COE. They also reported ongoing use of specific skills including resilience strategies, and planning teaching sessions.
Conclusion(s): Longitudinal FDP in medical education for CE can lead to a greater appreciation for the role of an educator, and identification with a COE. Investment in longitudinal FDP may have lasting impact on the clinical learning environment and the identity of faculty as an educator

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