Faculty Bibliography

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

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

Needs and Objectives: There is an increasing need for resident education on substance use disorders (SUDs). The purpose of our curriculum was to improve residents' knowledge, skills, and attitudes on treating patients with SUDs. Setting and Participants: First and second year residents from NYU's Primary Care, Internal Medicine program participated in the Block of Addiction Medicine (BAM!) curriculum. Clinical settings included buprenorphine/methadone clinics and outpatient treatment programs in a large, urban safety net hospital system. Description: BAMis an intensive two week curriculum focused on SUDs. To improve residents' knowledge, we included didactic sessions on substances, including alcohol, opiates, and tobacco. Sessions covered epidemiology, biology, and treatment, including pharmacologic options, with all residents receiving buprenorphine prescribing waiver training. BAMwas delivered by an interdisciplinary faculty that included addiction medicine specialists, department of health officials, and general practitioners, nurses, and social workers who have worked extensively with patients with SUDs. Workshops built skills including screening, brief interventions, and referral to treatment (SBIRT) and motivational interviewing. Residents attended buprenorphine/methadone clinics, outpatient treatment programs, and 12-step (AA/NA) meetings. Residents shared lunch in a non-clinical setting with patients in recovery to understand their perspectives on living with addiction. Evaluation: Residents' attitudes and self-perceived efficacy in treating SUDs were surveyed. Pre and post data was obtained on 15 of 16 participants. Using the medical condition regard scale (MCRS), an 11 item questionnaire on biases/emotions/expectations for treating patients with SUD, we found a statistically significant improvement in the composite score, from 44.46 to 47.0 (p=0.026). Of 15 residents, 11 reported improved ability to effectively screen for SUD, 10 reported improved comfort in screening patients for SUD, 12 reported improved knowledge in using medically assisted treatment (MAT), and 14 reported improved ability to effectively treat patients with MAT (all p<.001 in Wilcoxon signed rank test). Qualitative feedback showed residents felt this curriculum was an essential part of their education; one participant commented: "this is a course that should be offered to every medical care provider." Discussion/Reflection/Lessons Learned: BAMincluded a varied curriculum delivered by inter-professional faculty. Residents reported improved comfort in treating patients with SUDs and demonstrated a significant improvement on the MCRS in their already positive attitudes towards treating this patient population. Qualitative feedback indicated that residents enjoyed BAMand found it important to their training. Given the increasing need for providers who are able to effectively treat SUDs, courses such as BAMare an effective and essential part of residency. Further studies are needed to assess if the changes in residents' attitudes persist and whether we influenced practice

Learning Objective #1: Recognize vitamin deficiencies in a gastric bypass patient Learning Objective #2: Treat copper deficiency CASE: A 61 year old female with a past medical history of depression, hypothyroidism, dementia, profound insomnia, and remote history of gastric bypass presented with chronic dizziness and orthostatic hypotension with recurrent falls. She had multiple hospital admissions for dizziness, gait instability and falls. Associated symptoms included nausea and vomiting, fatigue, weakness, hypotension, hypoglycemia with low insulin levels, and worsening tingling and numbness in both legs. She denied using zinc containing denture cream or cold tablets. In the ED, her vital signs were stable and blood work was significant for pancytopenia, with a WBC count of 2.2, hemoglobin of 9.4 and platelets of 137. The levels of many vitamins and minerals were checked given her history of gastric bypass and she was found to have a normal iron level with transferrin saturation of 33%, normal levels of vitamins B1, B6, B9, B12, and selenium (58) and low levels of copper, ceruloplasmin, zinc, and vitamin D. CT and MRI of the brain were negative for acute pathology but significant for severe left temporal atrophy and overall global volume loss. Following admission, she was given intravenous fluids for persistent hypotension with eventual resolution after increasing her home dose of fludrocortisone and starting her on vitamin supplementation for her noted deficiency. She was discharged on a multivitamin with minerals daily, 50,000 units of Vitamin D weekly, 220mg of zinc sulfate twice daily, and 4mg of copper three times a day with close bariatric specialist follow up. IMPACT/DISCUSSION: Copper plays an essential role in the synthesis of many proteins and its deficiency can cause a variety different symptoms. Symptomatic copper deficiency is rare but can be seen in patients with a remote history of bariatric surgeries. In these patients, absorption of many minerals, including copper, is disrupted and supplementation may be necessary to prevent deficiency. This patient had been suffering from pancytopenia with a normal iron panel, which can be due to copper deficiency. Copper is a required cofactor in iron oxidation during hematopoiesis and its deficiency therefore Results in anemia. Patients with hypocupremia may present with gait abnormalities from myelopathy, as noted in our patient. Additionally, imaging showed cerebral atrophy, possibly related to demyelination, which can be seen in patients with Menkes Disease, a mutation causing defects in copper absorption. Despite having these symptoms for years, her copper levels had not been checked prior, which delayed the diagnosis of copper deficiency.
Conclusion(s): Many of the symptoms of copper deficiency are nonspecific, which may delay diagnosis until after many hospital re-admissions. It is essential to always consider copper deficiency in a patient with chronic neurologic symptoms and anemia with a remote history of gastric bypass surgery

BACKGROUND:The Society of Cardiovascular Computed Tomography (SCCT) recommends consideration of coronary artery calcium (CAC) scoring among individuals with a family history (FH) of coronary heart disease (CHD) and atherosclerotic cardiovascular disease (ASCVD) risk <5%. No dedicated study has examined the prognostic significance of CAC scoring among this population. METHODS:The CAC Consortium is a multi-center observational cohort study from four clinical centers linked to long-term follow-up for cause-specific mortality. All CAC scans were physician referred and performed in patients without a history of CHD. Our analysis includes 14,169 patients with ASCVD scores <5% and self-reported FH of CHD. RESULTS:This cohort had a mean age of 48.1 (SD 7.4), was 91.3% white, 47.4% female, had an average ASCVD score of 2.3% (SD 1.3), and 59.4% had a CAC = 0. The event rate for all-cause mortality was 1.2 per 1000 person-years, 0.3 per 1000 person-years for CVD-specific mortality, and 0.2 per 1000 person-years for CHD-specific mortality. In multivariable Cox proportional hazard models, those with CAC>100 had a 2.2 (95% CI 1.5-3.3) higher risk of all-cause mortality, 4.3 (95% CI 1.9-9.5) times higher risk of CVD-specific mortality, and a 10.4 (95% CI 3.2-33.7) times higher risk of CHD-specific mortality compared to individuals with CAC = 0. The NNS to detect CAC >100 in this sample was 9. CONCLUSION/CONCLUSIONS:In otherwise low risk patients with FH of CHD, CAC>100 were associated with increased risk of all-cause and CHD mortality with event rates in a range that may benefit with preventive pharmacotherapy. These data strongly support new SCCT recommendations regarding testing of patients with a family history of CHD.

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: 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