Faculty Bibliography

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

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

Morbidity and mortality associated with cardiovascular disease can be significantly modified through lifestyle interventions, yet there is little emphasis on nutrition and lifestyle in medical education. Improving nutrition education for future physicians would likely lead to improved preparedness to counsel patients on lifestyle interventions. An online anonymous survey of medical residents, cardiology fellows, and faculty in Internal Medicine and Cardiology was conducted at New York University Langone Health assessing basic nutritional knowledge, self-reported attitudes and practices. A total of 248 physicians responded (26.7% response rate). Nutrition knowledge was fair, but few (13.5%) felt adequately trained to discuss nutrition with patients. A majority (78.4%) agreed that additional training in nutrition would allow them to provide better clinical care. Based on survey responses, a dedicated continuing medical education (CME) conference was developed to improve knowledge and lifestyle counseling skills of healthcare providers. In postconference evaluations, attendees reported improved knowledge of evidence-based lifestyle interventions. Most noted that they would prescribe a Mediterranean or plant-based diet and would make changes to their practice based on the conference. An annual CME conference on diet and lifestyle can effectively help interested providers overcome barriers to lifestyle change in clinical practice through improved nutrition knowledge.

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

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

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: Moral distress occurs when the ethically correct action cannot be taken because of internal or external constraints. High levels of moral distress are associated with burnout in medical providers. A better understanding of factors associated with high moral distress during post-graduate training is crucial to executing interventions to lower rates of burnout during residency.
Method(s): This is a mixed Methods prospective observational cohort study that aims to enroll 90 internal medicine (IM) residents on a rolling basis from one IM residency program (12/2018-12/2019). Data is being collected by a series of 3 surveys over 1 year, using the previously validated Moral Distress Scale, to evaluate frequency and intensity of distress associated with specific situations experienced or witnessed by residents during training. This initial analysis, bivariate and multivariate regression of quantitative data from the first time point (survey #1), investigated associations between moral distress scores and demographic, training-specific, and intrinsic personal factors of participants. Analysis of qualitative open-ended questions further explored causes of moral distress and as well as coping mechanisms employed by residents.
Result(s): 32 IM residents (44% PGY-1, 28% PGY-2 and 28% PGY-3) have been enrolled thus far. 53% of resident participants identify as male, 43% as female (and 3% as other). 66% were " Categorical" residents, 25% " Primary Care (PC)," and 9.4% " Preliminary Year" PGY-1 Interns. Mean and median moral distress scores were: 66.8 (SD 31.0) and 61 (range 16-132). In multivariate linear regression " PC" residents had scores 31 pt. higher compared to " Categorical" residents (p=0.009). Male residents had scores 25pt lower than female residents (p=0.008), and PGY year conferred an incremental score increase of 11 pt. per year (p=0.057). The model was adjusted for covariates: PGY-year, gender, age, and/or program type. Themes regarding causes of moral distress included: lack of resources, situations when patient care is dictated by cost-saving measures, and aggressive futile care. Coping mechanisms included: debriefing with team members or others outside of work, active individual reflection, exercise/yoga/meditation, participating in activities and social events outside of medicine, reflective writing/journaling, and suppression and/or distraction.
Conclusion(s): In this preliminary analysis, residents in the PC track have higher average moral distress scores. It is unclear whether residents prone to more moral distress self select into this track or whether distress is related to differences in training between PC and categorical tracks. Additionally, more senior residents had average higher scores. This supports the theory of residual moral distress; an increasing amount of moral distress is experienced as a provider witnesses/experiences distressing events over time. Most coping strategies involve social connection and reflection

Background: Emergency department (ED) care decisions often hinge on the result of a diagnostic test. Frequently there is a lag time between a test result becoming available for review, and physician decision-making based on that result. Push notifications to physician smartphones have demonstrated improvement in this lag time in chest pain patients, but have not been studied in other ED patients. We implemented a system by which ED providers can subscribe to electronic alerts when test results are available for review via a smartphone or smartwatch push notification, and hypothesized that this would reduce the time to make clinical decisions. Method(s): This was a retrospective, multicenter, observational study in three emergency departments of an urban health system. We assessed push notification impact on time to disposition or time to follow-up order in six clinical scenarios of interest: chest x-ray (CXR) to disposition, basic metabolic panel (BMP) to disposition, urinalysis (UA) to disposition, respiratory pathogen panel (RPP) to disposition, hemoglobin (Hb) to blood transfusion order, and D-dimer to computed tomography pulmonary angiography (CTPA) order. All adult ED patients during a one-year period of push notification availability were included in the study. The primary outcome was median time from result availability to disposition order or defined follow-up order. Median times with interquartile ranges were determined in each scenario and the Mann Whitney (Wilcoxon) test for unpaired data was used to determine statistical significance. Result(s): During the study period there were 6,115 push notifications from 4,183 eligible ED encounters (2.7% of all ED encounters). All six scenarios studied were associated with a decrease in median time from test result availability to patient disposition, or from test result availability to follow-up order, when push notifications were employed: CXR to disposition (24 minutes, p<0.01), BMP to disposition (12 minutes, p<0.01), UA to disposition (50 minutes, p<0.01), RPP to disposition (43 minutes, p<0.01), D-dimer to CTPA (8 minutes, p<0.01), Hb to blood transfusion (19 minutes, p=0.73). Conclusion(s): Implementation of a push notification system for test result availability in the ED was associated with a decrease in lag time between test result availability and physician decision-making