Faculty Bibliography

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

Learning Objective #1: Recognize 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

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

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

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

Needs and Objectives: In the changing landscape of healthcare, physicians must be adaptive, visionary and evidence-based in their approach to care Medical education must be adjusted to allow learners to gain skills that prepare them to function effectively in this new paradigm. In order to meet these needs, we developed a community based curriculum with emphasis on transitions of care, population health and innovation of care. Setting and Participants: Curriculum was developed as part of a new NYU Internal Medicine Residency Community Health Track, housed at NYU Langone Hospital-Brooklyn, a community based, academic teaching hospital. Ambulatory training is based at the Family Health Centers at NYU Langone, a network of FQHCs. Both the hospital and FQHCs serve a vulnerable, diverse community in south Brooklyn. To date we have recruited one class of 10 interns. As of July 2020 we anticipate having a full track consisting of 30 residents. Description: Our first year curriculum aims to develop a framework for thinking about community health introducing key concepts such as population-based care, novel delivery of care, and interdisciplinary collaboration. Early in their training, residents completed a community assessment using observational data, interviews and census track data. These assessments paired with collaboration with CHW and community organizations gave them first hand exposure to our area's specific challenges and gaps in care. The residents began to develop skills in home care by working with an interdisciplinary team of doctors, nurses and CHWs. Additionally, they participated in a transitions of care workshop, examining their own hospital patients who had been readmitted and identifying best practices for hospital discharge. Evaluation: A multi-method evaluation plan is essential as we evaluate and strengthen the curriculum. Qualitative feedback is gathered at regular intervals throughout the year along with surveys of trainees. Initial Results suggest that curricula is well-received by residents. Aggregated longitudinal educational data including resident self-report, 360^oevaluations and performance-based assessment, (OSCEs, USP visits) will contribute to program evaluation. The most important outcome will be how these trainees practice once they have graduated. We plan to use postgraduate surveys to judge the impact of the curriculum. Discussion/Reflection/Lessons Learned: We adapted curriculum to focus on our particular community and created innovative programs to improve the population's health. Essential to these accomplishments was our partnership with learners and our reliance on their feedback to guide curriculum development. Allowing trainees to explore their interests has lead to visionary projects. We have learned that by being flexible and adapting to the learners' needs and interests we can serve our community in deeper ways than we had initially anticipated. However, structural limitations of the clinic coupled with institutional changes resulted in a slower time frame for clinical adaptations

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