Faculty Bibliography

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: 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

Statement of Problem Or Question (One Sentence): As communication among patient care team members is often dangerously fragmented and effective collaboration becomes essential to provide safe hospital care for patients, we implemented the Daily Medicine Rounding Tool (DMeRT) that improved collaboration between the physician and nurse. Objectives of Program/Intervention (No More Than Three Objectives): 1. We aimed to promote a patient-centered, highly reliable rounding tool to reduce hospital adverse events by streamlining real time communication between nurses and physicians. 2. We hypothesize that this tool will decrease the need for frequent calls throughout the day, ultimately improving team productivity and overall staff satisfaction. Description of Program/Intervention, Including Organizational Context (E.G. Inpatient Vs. Outpatient, Practice or Community Characteristics): In our institution, the Epic's default patient dashboard columns included patient name, venous thromboemboli (VTE) prophylaxis, Medical Orders for Life Sustaining Treatment (MOLST) completion, glycemic control, and medication reconciliation completion. Expanding upon these prior default columns, we partnered with information technology and nursing to create a customized dashboard that included additional informational columns extracted from the documentation in the charts, to include the administration of intravenous fluids, oxygen supplementation, last bowel movement recorded and high risk medications (anti-coagulants, anti-epileptics, furosemide, opioids, and benzo-diazepines). We then trained the physicians and nurses to discuss each patient using the customized DMeRT dashboard during interdisciplinary rounds. The average time spent on the DMeRT is 15 minutes for a total 10 patients. This helps as a reminder and the identification of potential pitfalls and safety concerns. The DMeRT was instituted on a 30 bed medical unit (5500) on June 1, 2018 with iterative improvements to content. Measures of Success (Discuss Qualitative And/Or Quantitative Metrics Which Will Be Used To Evaluate Program/Intervention): We will analyze data pre and post intervention to assess for impact on reducing medication errors during hospitalization, hospital acquired VTE events and improvement in glycemic control. Finally we will track MOLST completion, medication reconciliation compliance, constipation and fluid overload events added to the patient's problem list 48 hours prior to discharge. Findings To Date (It Is Not Sufficient To State Findings Will Be Discussed): To date, the unit which implemented the intervention had an improvement in the Quality Hyperglycemia Scores (method used to evaluate inpatient glycemic management) from 56 in 4/2018 to 95 in 12/2018. There was an improved MOLST completion from 14% in 4/2018 to 83% in 12/2018. A Preliminary survey of 15 nurses on unit 5500 showed that 80% reported that they rarely need to call house staff within 2 hours of completing the rounding tool and 66% of nurses were satisfied with the DMeRT. Key Lessons For Dissemination (What Can Others Take Away For Implementation To Their Practice Or Community?): During hospitalization, multiple aspects of patient care are overlooked while we focus on the admitting diagnosis, necessary diagnostics and treatments. Medication errors during hospitalization are commonly caused by breakdowns in communication and associated with substantial risk. This is a simple tool that utilizes information technology to efficiently and systematically review standardized aspects of care

Needs and Objectives: Didactic training in motivation interviewing (MI) lacks efficacy, because opportunities to practice skills while being directly observed are rare. The goal of our educational innovation was to train interns in the advanced communication skills of motivation interviewing through a group observed standardized clinical experience (GOSCE). Our Learning Objectives were as follows: After an experiential learning session on MI, interns will be able to: 1. Identify opportunities to use MI with patients 2. Recognize "change talk" from a patient as an opportunity to use MI techniques 3. Use MI techniques when discussing behavior change with a patient Setting and Participants: 46 internal medicine interns in an academic internal medicine residency program. Description: Each session began with a 20 minute review of MI for behavior change given by a psychologist trained in Motivational Interviewing. Then, interns participated in a 3 station, one-hour long Group Observed Standardized Clinical Exercise (GOSCE). Interns worked in teams of 3, and for each station, one of the 3 interns was the active physician, while the other 2 observed the encounter. Each intern had an opportunity to be the active physician for a case. Each case was observed by one or two faculty members, one of whom was a psychologist trained in MI. After a 10 minute interaction with the standardized patient, the active physician received feedback on their MI skills and debriefed the encounter with the faculty and their peers. After the 3 cases, the session concluded with a group debrief and summary of the experience. Interns completed a retrospective pre/post survey to assess the impact of the session. Evaluation: Residents reported statistically significant improvement in all domains, including confidence with identifying opportunities to use MI, comfort using reflective and summary statements during MI, and likelihood of using motivational interviewing in future patient encounters. Qualitative comments after the session reflect that residents developed an appreciation for silence as a tool during MI, felt comfortable with tools such as decisional balance, and recognized the value of patient centered-ness during MI. Discussion/Reflection/Lessons Learned: Our interprofessional educational team (psychologists and internists) provided different perspective for both learners and our internal medicine faculty. Our residents appreciated practicing skills and receiving feedback in real time. This academic year (one year after the intern GOSCE), these same learners will participate in an OSCE that includes a case requiring motivational internviewing skills, and we will evaluate the durability of motivation interviewing skills taught during this session. We are interested in expanding opportunities to use GOSCE as a low stakes skills practice and development tool

Needs and Objectives: Superior clinical reasoning is a hallmark of the expert clinician. However, to a passive listener at a traditional case conference, the process by which this expert arrives at a diagnosis may not be obvious. Discussion often focuses on medical knowledge, rather than on the Methods the expert uses to reach a Conclusion. Experts vary in their ability to describe how they approach a case, and it is debatable whether narratives produced in this manner are in fact reliable representations of their mental processes. Teaching clinical reasoning can thus be challenging even for experienced faculty. In response, we designed a podcast series using actual cases to explore the conscious and unconscious habits and strategies used by physicians. Our intention was to immerse listeners in the language of clinical problem solving in an accessible and interactive way. Setting and Participants: Hoofbeats is one of several series that comprise the CoreIM podcast. It is targeted at trainees and medical professionals across all specialties within internal medicine. Description: Hoofbeats listeners play the role of the clinician, as a difficult case is presented in stepwise fashion with pauses to allow revision of an impression or differential. Listeners hear a discussant work through the case, accompanied by commentary from the show's hosts, who interpret and elaborate on the discussant's reasoning behaviors. Clinical pearls, useful schema, and biases are highlighted. To reinforce the challenge, a visual representation of the case is sent out via social media. In some episodes users can solve an interactive version of the case on the online database HumanDx; the resulting collective differential is then explored within the episode. Evaluation: From March to December 2018 we released six Hoofbeats episodes, with over 64,000 total downloads by listeners across 170 countries. In our descriptive analysis of feedback, we found that listeners valued the explicit analysis of the problem-solving behavior of experienced clinicians. Interactive elements successfully engaged our listeners, who actively attempted cases and reflected on their reasoning. Through role modeling from the hosts, listeners reported greater confidence articulating and teaching clinical reasoning concepts. Interestingly, commentary on particularly challenging points in a difficult case led our listeners to appreciate the honesty and humility of our hosts and experts, who frequently recognized their own shortcomings. Discussion/Reflection/Lessons Learned: Decades of research into clinical problem-solving have produced a terminology now familiar to many trainees and medical professionals, such as the practice of "problem representation" or the concept of the "availability heuristic." Many of these abstract concepts originated in behavioral science and artificial intelligence programming, and do not lend themselves naturally to book or lecture-based learning. However, our experience with Hoofbeats suggests there is significant interest among learners in the practical application of these constructs

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

Learning Objective #1: Recognize methemoglobinemia & its sequelae Learning Objective #2: Recall medications that confer risk of iatrogenic methemoglobinemia & treatment CASE: An 89-year-old woman was admitted with abdominal discomfort plus five days of dysuria and urinary frequency. Previously, she had seen a urologist for chronic dysuria and was prescribed estrogen cream for vaginal atrophy. On admission, her vital signs were notable for oxygen saturation of 88%, unresponsive to oxygen supplementation. Other clinical findings included jaundice, right upper quadrant and suprapubic tenderness, anemia (hemoglobin 8 g/dL), serum creatinine 2. 2 mg/dL, unremarkable liver function testing and ultrasound imaging, plus a uri-nalysis consistent with a urinary tract infection (UTI). Her chest X-ray was unremarkable and an arterial blood gas (ABG) obtained off of oxygen demonstrated normal partial pressure of oxygen (PaO2). Given the discrepancy between oxygen saturation on pulse oximetry and PaO2, met-hemoglobinemia was suspected. Co-oximetry revealed oxyhemoglobin 70%, methemoglobin > 21%. The patient denied recent benzocaine, nitrates, or dapsone use, but eventually disclosed taking phenazopyridine for several weeks prior to admission. Intravenous methylene blue was administered, ceftriaxone was given for her UTI, and supportive care was provided until her clinical status returned to baseline. IMPACT/DISCUSSION: Methemoglobinemia, a condition whereby functional anemia and tissue hypoxia are precipitated by acutely elevated methemoglobin concentration, is often iatrogenic. Nonspecific symptoms plus anemia and acute kidney injury (AKI) can be mistaken for many ailments, highlighting the importance of thorough medication review and having a high index of suspicion when there is a recent use of medications such as oxidizing agents (e.g. topical anesthetics, dapsone), nitrates, phenytoin, or antimalar-ials. The pathophysiology of acute respiratory distress in methemo-globinemia relates to the reduced erythrocyte oxygen-carrying capacity of functionally impaired hemoglobin. Skin discoloration, he-molytic anemia, and AKI have also been associated with phenazopyridine toxicity. The pathophysiology of AKI is still being investigated but may be multifactorial, including renal tubular epithelial cell injury, heme pigment-induced nephropathy from hemo-lytic anemia, and hypoxic injury from methemoglobinemia itself.
Conclusion(s): Methemolglobinemia presents with non-specific symptoms (e.g. headache, dizziness, dyspnea, fatigue, mental status changes). When a patient exhibits hypoxia unresponsive to supplemental oxygen, chocolate-brown hued arterial blood, and a discrepancy between pulse oximetry and ABG, methemoglobinemia should be at the top of one's differential. History-taking should include a thorough medication review (including over-the-counter agents) and chemical exposures. Once the diagnosis is confirmed with co-oximetry, methylene blue and supplemental oxygen should be given when methemoglobin level is greater than 20%

Background: Inter-provider variability is a major source of low-value care. The dissemination of clinical practice guidelines (CPGs) has targeted this variability, yet 44% of physicians are non-adherent to CPG. This may be due to factors including exceptionalism and incentive misalignment that present a conflict between comprehensiveness and prudence in work-up. A subset of super-utilizers are notable outliers: fewer than 0.5% of physicians account for 10% of healthcare costs. Super-utilizers order labs, request consults, order imaging, and prescribe medications at rates 30%, 140%, 14%, and 25% higher than the general population. We sought to quantify provider-specific low-value test ordering behaviors across three 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 a large urban, safety-net hospital. Diagnostic orders were extracted via retrospective chart review. Scenario-specific appropriateness of diagnostic testing was determined by referencing United States Preventative Services Task Force (USPSTF) and specialty society CPGs. "Excessive" tests were those not explicitly indicated for a given scenario in either USPSTF or society CPGs (versus "indicated" tests). "Discretionary" tests were those conditionally indicated, pending patient-specific factors (such as hemoglobin A1C, pending BMI).
Result(s): One or more excessive tests were ordered in 44%, 22%, and 17% of Well (n=124), Fatigue (n=148), and Asthma (n=148) encounters respectively. Percent of orders that were excessive were 18%, 8%, and 10%, respectively. On average, 1.3 (+/-1.7) excessive orders were made. Within each case, rates of excessive ordering were positively correlated with rates of indicated and discretionary ordering, and negatively correlated with rates of omitting indicated tests. For example, in Fatigue, the correlation between excessive and indicated orders was 0.38, between excessive and discretionary orders rates was 0.59, and between excessive and omitted-indicated tests was-0.25 (all p< 0.05). A similar, statistically-significant pattern was found for the other two cases. 10 (21%) and 4 (8%) of 48 residents completing all scenarios demonstrated excessive ordering at rates atleast 1 and 2 standard deviations above the mean, respectively.
Conclusion(s): Introducing USPs representing clinical scenarios revealed marked inter-provider variability. Positive associations between rates of excessive, discretionary and indicated ordering suggest tendencies for comprehensiveness over prudence. Over one-fifth of residents completing all 3 cases were high-utilizers, and nearly one in ten were super-utilizers. Awareness of provider-level ordering tendencies can guide education and interventions supporting appropriate diagnostic use

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