Faculty Bibliography

LEARNING OBJECTIVE #1: Discuss the clinical utility and mechanism of action of a widely used novel immunotherapeutic agents. LEARNING OBJECTIVE #2: Highlight the incidence of endocrinopathies associated with Ipilimumab and Nivolumab. CASE: A 70 year old female with metastatic melanoma presented to the emergency department with fatigue and lethargy for one month. She had recently completed 6 cycles of Nivolumab and Ipilimumab and was currently receiving Nivolumab monotherapy. Over the past month she had worsening fatigue associated with nausea and decreased appetite. Lab work one week prior to admission was significant for newly elevated TSH and low T4, and thyroid replacement therapy was initiated. On the day of admission, she had a syncopal episode at home prompting presentation. On arrival, she was hypotensive to 89/57. Lab work was significant for hyponatremia, hypokalemia, and hypochloremia. Due to concern for adrenal insufficiency, she was started on stress dose hydrocortisone. An AM serum cortisol was 1.5 and ACTH level was undetectable. FSH and LH levels were also low. An MRI of the brain was notable for enhancement of the pituitary gland suggestive of hypophysitis, which was likely a side effect of her immunotherapy. IMPACT: Ipilimumab and Nivolumab are novel immunotherapeutic agents used in the treatment of melanoma, with research investigating their use into other malignancies as well. Endocrinopathies are relatively common side effects of these agents, especially when given as combination therapy. Nonspecific complaints, such as fatigue and nausea in our patient, should warrant a thorough investigation for endocrinopathies in patients with treatment exposure to ipilimumab and/or nivolumab. DISCUSSION: Nivolumab and Ipilimumab are novel immunotherapeutic agents that are currently used for metastatic melanoma and squamous lung carcinoma. Nivolumab antagonizes the binding of Programmed Cell Death Ligand 1 to the programmed cell death 1 receptor (PD-1), activation of which would normally promote T-cell apoptosis. Ipilimumab antagonizes the cytotoxic T lymphocyte-associated antigen 4 (CTLA-4), preventing down regulation cytotoxic T lymphocytes. Endocrinopathies are relatively common side effects of checkpoint inhibitors and are thought to be result of auto-immune inflammation. They can manifest as primary hyper/hypothyroidism, primary adrenal insufficiency and/or hypophysitis thereby affecting the multiple hormonal systems. A retrospective review from Memorial Sloan Kettering showed an incidence of hypophysitis of 8 and thyroiditis of 6% following treatment with ipilimumab. The incidence of hypophysitis and thyroiditis increased to 9 and 22% respectively in patients who received combination therapy with ipilimumab and nivolumab. Our patient seemingly developed primary hypothyroidism and hypophysitis causing a secondary adrenal insufficiency secondary to her combination therapy. The initiation of levothyroxine therapy likely precipitated her adrenal insufficiency leading to her syncopal event

BACKGROUND: At NYU, as part of a comprehensive objective structured clinical skills exam, experienced medical educators judge clinical knowledge, decision-making, and clinical reasoning skills of trainees based on their patient notes. Despite being rubric-driven, this task requires tremendous time and effort to establish consistent scoring, delaying and limiting individualized feedback. We conducted pilot machine learning text classification studies to establish if accurate automated scoring of clinical notes is possible. METHODS: As a use case, we tested 100 student written clinical notes from7 standardized patient cases (Vision Loss, Tel Diarrhea, Difficulty Sleeping, Shoulder Pain, Failure To Thrive, Abdominal, Pain, Palpitations) that had been scored for quality of clinical reasoning by faculty on a 1-4 scale. In order to assess performance of NLP strategies to categorize students in meaningful groups we dichotomized students based on their faculty given scores by case into "failing" (score of 1, 5-18 students per case) and "passing" (score 2,3,4). We treated each task as a binary classification task in a text classification pipeline. First, we treated each note as a bag of tokens and weight each token with term frequency-inverse document frequency (TFIDF) a numerical statistic that reflects howimportant aword is to a document. We then applied 3 different classification algorithms (random forests, support vector machines, and Bayesian logistic regression) and measured discriminatory performance using Area Under Curve (AUC) in a cross validation evaluation design. RESULTS: TFDIF performed with AUCs between 0.669 and 0.905. Logistic regression provided the highestAUC in four cases: Difficulty Sleeping (0.905), Shoulder Pain (0.618), Failure To Thrive (0.717) and Abdominal Pain (0.892). As we observed the highest AUCs in Difficulty Sleeping and Abdominal Pain cases, we have begun to refine the algorithm for these two cases by identifying the importance features that lead faculty to give students to a higher grade and improve the accuracy of NLP based scoring. Promising features include the presence and sequence of certainwords in the problem representation, sentence length in the management section, ranking of the differential diagnosis, sequence between key words (e.g. rule out appendicitis), and evidence of "thinkingness" or what many call semantic qualifiers. CONCLUSIONS: With additional effort to build targeted case specific classifiers for clinical content and reasoning, a validated machine-learning model may achieve partial or full automation of grading of the notes. This work, which builds on decades of clinical decision-making and critical reasoning research, may provide medical trainees with more and potentially better feedback; facilitating learning of clinical reasoning, freeing faculty to coach this process, and in the long run impacting healthcare quality and patient safety

NEEDS AND OBJECTIVES: Standardized Patients (SPs) are integral to health care professions (HCPs) training. We must understand this workforce, make effective use of SPs' skills, and ensure they accurately portray cases and rate learners. To be authentic, simulation should reflect the demographics of the population served, while providing exposure to less commonly seen patients. We created an SP database to facilitate our work with SPs; review their demographic characteristics; and align information on SP performance -to better serve our educational mission. SETTING AND PARTICIPANTS: NYSIM (Simulation Center for NYU Langone and the City University of NY) serves hundreds of HCP training programs for learners at all levels. While sharing common resources, many programs independently recruit and train SPs. DESCRIPTION: We fielded a web-based survey for SPs and staff to populate the database. Survey items were iteratively reviewed by staff and SPs to ensure items elicited key information. Questions included basic demographics; SP experience/training; other professional background; and relevant physical findings (eg scars, cardiac findings). SPs also uploaded a headshot and resume. Staff separately input information about SPs' work on cases and programs; information about case portrayals; types of cases for which the SP is best suited, and other relevant information. EVALUATION: To date, we have 232 SP surveys, representing the majority of SPs at NYSIM. Demographics included gender (43% male, 56% female, 1% transgender), age range (x = 34.9 years, range teen to 75+) and selfidentified race (71% Caucasian, 17% African-American, 25.6% Asian/South Asian, 3.5% Middle Eastern, 3% Native American/Pacific Islander and 9% other). 22%are bilingual, with over 20 languages represented. SPs had a broad range of SP experience (x = 2.8 years, S.D. = 1.8, range 0-20 years). Almost all SPs were trained in basic case portrayal, with others being trained in aspects of the physical exam, emotional issues, giving feedback, and high stakes rating. SPs bring other skills to their work, including teaching (75%) or healthcare (12%). Survey information helps educators recruit SPs and identify (re)training needs. SPs who perform high stakes exams or are Unannounced Standardized Patients are shielded from general recruitment in order to maintain their anonymity. DISCUSSION/REFLECTION/LESSONS LEARNED: An SP database is useful for a high volume simulation center. Information in a searchable SP data base allows programs to understand the potential pool and expertise of SPs, and to track learners' exposure to specific SPs (this is relevant as our internal data reveal that SPs with more experience tend rate towards the middle of the scale). The demographic characteristics of our SPs broadly match the profile of our healthcare systems, and tracking the data allows us to maintain a good fit between SPs and our environment

BACKGROUND: The shift toward a Patient Centered Medical Home has redefined healthcare delivery to be a patient centered affair. While this is beneficial, it also calls for patients to be more activated in the doctor's office and responsible in their self-directed care outside of the office. For patients with chronic diseases, the burden of illness is even higher and requires significantly more effort in disease selfmanagement. We developed 4 hour Patient Empowerment Program (PEP) to bridge that gap through a program training patients with diabetes in the skills necessary to communicate effectively with providers and engage in shared decision making (SDM). Previously, we reported improved diabetes self-care behaviors at 6 months post intervention based on standardized questionnaires. This study examined participants' perspectives on PEP from 1-2 years post intervention. METHODS: 71 patients with type 2 diabetes mellitus were recruited from 2 urban safety-net hospitals to participate in PEP. 33 patients completed the intervention and 28 patients completed a 6-month follow-up assessment. Participants were predominantly low-income, racial minorities, with limited health literacy (Newest Vital Sign M= 2.21, SD = 1.67). We reached 22 of those 28 participants, at 11 to 20months post intervention (M= 16, SD = 2.31). They were interviewed via telephone, with structured open-ended questions asking them to reflect on what they took away from the classes, and whether they'd behaved differently during doctor visits or cared for their diabetes differently since the classes. A qualitative analysis was made of these responses, using Dedoose software to assist in analysis. RESULTS: All 22 patients recalled PEP and could identify key concepts from it. Participants referenced the doctor-patient relationship, from "how to improve relationship with my doctor" to "practicing role of doctor and patient in interaction and relationship". 86% of participants identified changes in their behavior since PEP- 36% identifying that they share more information with their doctor now than they did before, 18% reporting that they ask more questions, and another 18% reporting that they are more proactive in their diabetes care. When asked about their diabetes self-management, prevalent themes were better diet/food choices, exercise, and adherence to medication. 3 patients reported losing weight since the classes. CONCLUSIONS: Despite follow up occurring almost a year later for some, and almost 2 years for others, the message of PEP was clear and compelling. Participant's perspective on their role as a patient changed from a passive recipient of healthcare to a more engaged and activated one. They felt empowered to participate in SDM with their doctors and more comfortable speaking up for their preferences. While further validation is necessary, PEP offers an important way to prepare patients to become true partners with their providers

LEARNING OBJECTIVE #1: Recognize the clinical features and complications of Lemierre's syndrome. CASE: A healthy 25-year-old male presented with 8 days of progressively worsening sore throat, fever and neck swelling which were unresponsive to 2 outpatient courses of clarithromycin. On presentation, he was febrile, tachycardic, hypotensive, tachypneic and hypoxic. Physical examination was significant for a palpable left-sided neck mass, trismus, and muffled voice. Initial labs revealed a white blood cell count of 26k, creatinine of 1.9mg/dL, and serum lactate of 4.5mg/dL. The patient was intubated for airway protection, and started on antibiotics and vasopressors. Ultrasound and CT imaging revealed left tonsillar, peritonsillar, and sublingual abscesses, pulmonary septic emboli, bilateral parapneumonic effusions and left internal jugular (IJ) thrombus. Wound cultures of left tonsillar abscess grew Fusobacterium necrophorum and antibiotics were narrowed to piperacillin-tazobactam. He underwent left IJ ligation and left lower lobe lobectomy, and gradually improved and was discharged home on a prolonged course of antibiotics. IMPACT: Lemierre's syndrome is a potentially fatal disease that can cause rapid decompensation if untreated. When a young adult presents with worsening symptoms of acute pharyngitis, one must have a high suspicion for this disease in order to diagnose and treat it early. DISCUSSION: Lemierre's syndrome is a rare and serious disease entity that primarily affects healthy young adults with an incidence of 1 in 1 million and a mortality rate of 4-12%. It involves oropharyngeal fusobacteriuminfection that can form abscesses and internal jugular thrombophlebitis. IJ thrombophlebitis results in bacteremia with septic emboli, commonly to the lungs and joints. The prevalence of Lemierre's syndrome has been rising in recent years due to more judicious use of antibiotics for acute pharyngitis.2 This is also attributed to rising resistance of fusobacterium to macrolides that are often prescribed for pharyngitis, as illustrated by our patient who was initially treated with clarithromycin

BACKGROUND: Entrustable Professional Activities (EPAs) and milestones are expert judgments made based on many formative assessments. Their validity is dependent on the number of assessments but attention is increasingly being paid to having a "fair" sample of observations equally distributed across residents and contexts. OSCEs provide such a consistent, fair sample of behavior assessed under controlled conditions but have mostly used been used to provide granular skills feedback. We explore how faculty judge the "entrustability" of residents based on observing OSCE cases and then how these entrustments relate to OSCE skills performance. METHODS: In an 11-case OSCE for primary care residents (n = 25; PGY1-3), SPs rated skills in communication (information gathering, relationship development, education/counseling), assessment, patient education (case-specific), physical exam, professionalism, treatment plan, patient satisfaction and patient activation. Summary scores were calculated as%items rated well done (vs not or partly done; internal consistency > .72). Faculty observers then judged how much supervision the resident would need in actual practice to handle the case: 1-requires direct supervision, 2-requires indirect supervision, 3-ready for unsupervised practice, or 4- can supervise others. Mean entrustment rating across cases was correlated with clinical skills. RESULTS: Mean entrustment =2.46 (SD .37), falling between requires indirect supervision and ready for unsupervised practice. On average, residents were judged to need direct supervision in .40 cases (SD .65), indirect supervision in 4.76 (SD 2.03), ready for unsupervised practice in 2.92 (SD 1.80), and able to supervise others in 1.07 cases (SD 1.15) with PGY1 residents needing direct and indirect supervision in more cases than PGY2 and 3 (p = .037). Associations between OSCE performance and faculty entrustment ranged from essentially zero (communication sub-domains of information gathering and education/counseling; case-specific patient education; patient satisfaction) to negative (communication sub-domain of relationship development r = -.25, p = .16; professionalism r = -.21, p = .22) to positive (case-specific assessment, r = .35, p = .07; physical exam r = .30, p = .13; treatment plan r = .40, p = .04; patient activation r = .51, p = .008). Associations between skills performance and entrustment ratings varied by case. CONCLUSIONS: OSCEs provide a valuable opportunity for faculty to make entrustment judgments based on observing the same, complete encounter across many trainees. Entrustment judgments appear to be capturing elements of competence related to but different from SP assessments of performance, including especially "bottom line" aspects of practice such as assessment, physical exam, treatment plans and patient activation. Interestingly, we consider patient activation skills to be an "educationally sensitive patient outcome" i because both teachable and associated with patient outcomes and our results support the importance of this skill set

BACKGROUND: All physicians need to be skilled at diagnosing, treating, and managing depression. We designed an unannounced standard patient (USP) case to assess residents' clinical skills in addressing depression and explored how those skills are associated with residents' general clinical skills in order to design targeted curriculum on depression. METHODS: The USP was a 26 y.o. male presenting as a new patient to a clinic complaining of fatigue and problems sleeping. Goals of the case were to diagnose a common presentation of depression and make a treatment/follow-up plan. The USP was trained to have a positive PHQ 2 &PHQ 9, family history of depression, and be willing to engage in medication and/or therapy if offered. A post-visit checklist was used by the SPs to assess communication, patient education, and assessment skills using behaviorally anchored items rated as not done, partly done, or well done. A systematic chart review was conducted to examine treatment, quality of documentation, and referrals. Case fidelity was checked by audiotape and confirmed by PHQ 9 score in the EHR. Evidence based treatment was defined as prescribing an SSRI and/or providing a psychiatric referral; if neither of those, scheduling follow-up for within 2 weeks. RESULTS: 122 residents saw the USP case from 2009-2015. Mean visit length = 45 min, SD 25 (14 to 183 min). The patient was screened for depression with a PHQ 2 in 93% of visits; 82% also had a PHQ 9. Overall, 77 residents (63%) provided appropriate treatment: 8% prescribed an SRRI, 23% provided a referral, 19% did both, 7% prescribed a sleep aid and <2 week follow-up, and 43% provided a combination of these treatments. 45 residents (37%) did not provide appropriate treatment: 27 (60%) prescribed a sleep aid and follow-up >2 weeks and 18 (40%) provided no treatment/referral and follow-up >2 weeks. There were no differences in exploration of medical history or substance use, but 83% of residents who treated appropriately had a PHQ 9 compared to 62% of residents who did not treat appropriately. 71% also included depression on the problem list compared to 13%of residents who did not treat appropriately. Residents who treated appropriately had significantly better clinical skills assessed by the USP including: overall communication (71% vs. 54%, p = 0.00), information gathering (72% vs. 55%, p = 0.01), relationship development (75% vs. 60%, p = 0.03), patient education (55% vs. 21%, p = 0.00), and patient activation skills (33% vs. 13%, p = 0.01). CONCLUSIONS: Although almost all residents obtained the relevant information, only about 50% of residents diagnosed depression. PHQ 9 appears to be associated with providing more effective treatment, supporting the importance of health system screening protocols. Residents' communication and depression-specific patient education and activation skills seem to be related to how they identify and manage depression, suggesting that interventions to build these skills may lead to higher quality care

BACKGROUND: It is critically important for medical schools to understand how well prepared their graduates are for residency and yet we do not have a full understanding of how well competencies, assessed in medical school, transfer to residency. This study explores how communication skills measured in a high-stakes, rigorous, comprehensive OSCE in the 3rd year of medical school are related to performance in a similar OSCE in residency and to Residency Program Directors' ratings of intern competence. METHODS: We analyzed communication skills from three time points in a longitudinal cohort of NYU graduates who entered our Internal Medicine Residency (n = 42). 39 provided consent for their GME-UME data to be compiled into a longitudinal, de-identified educational research database through an IRB-approved Registry. Communication skills were measured using a behaviorally anchored 15-item checklist across the 8-station, pass/fail, MS3 OSCE and then midway through PGY2 of residency in a 6- station OSCE (score =% of items rated well done). SPs also provided an overall rating of communication skills (not recommend, with reservations, recommend, highly recommend). In between, at the end of intern year, residents were also rated by their Program Directors on communication skills (and other competencies) using a 4-pt scale. RESULTS: OSCE communication performance assessed in medical school was modestly associated with performance in residency (r = .26, p = .07) but not with Program Directors' ratings of residents' communication skills as interns (r = .11, p = .28). Number of cases in which medical students were "not recommended" for their communication skills was negatively associated with residency OSCE communication scores (r = -.33, p = .05) and positively associated with number of "not recommends" (r = .46, p = .01) but not with Directors' ratings of interns (r = -.08, p = .49). Number of not recommends independently explained more variance in subsequent residency communication scores than did medical school performance (9% vs. 5%). While average OSCE communication scores improved from medical school to residency (65 to 71%), those with 2 or more "not recommends" improved significantly more than those with 1 or no not recommends. Overall, most learners' (21/39) communication scores improved substantially; less than a quarter (7) decreased; and about a quarter (11) were stable. CONCLUSIONS: While communication scores from medical school are associated with similarly measured scores in residency, SPs' decisions to "not recommend" students appear to serve as an independent indicator of future skill deficits. Patterns of change, however, are not necessarily straightforward: students with the most "not recommends" improved the most. The ability to track competency assessments longitudinally is essential for understanding the transition from medical school to residency and future research will benefit from larger sample sizes and the inclusion of learner characteristics that may explain developmental patterns

BACKGROUND: As healthcare increases demands, primary care physicians need evidenced-based, patient-centered care coordination, effective use of information technology, interdisciplinary team functioning and shared decision-making skills more so in underserved areas. In 2008, we documented 20 years of the NYU/Bellevue Primary Care Internal Medicine Residency Program (NYUBPC) on readiness for practice1. In light of the recent primary care changes we assessed our recent training of Primary Care Residents in high quality, person-centered, systems-savvy, team-based care for the underserved. Specifically we aimed to: 1. Assess the NYUBPCP impact on graduate career choices, values and style 2. Elicit reflections that illustrate complexities in educating primary care physicians METHODS: We surveyed 56 graduates of the NYUBPCP from 2007-2014. The 44 question survey included 12 open-ended questions about career path, current practice, preparedness for practice and specifics about how aspects of training provided necessary skills and knowledge. Responses were unidentified. We received 37 responses, (66%). RESULTS: 36 respondents currently provide clinical care, with about 40% of their time spent in a primary care setting (S.D. 32%). On a 4- point scale 85% either agreed or strongly agreed with Primary Care as a career choice. 74% felt prepared for the challenges of a primary care practice, rating clinical experiences with underserved communities, and the psychosocial, clinical epidemiology and health policy focus as essential aspects of training. All but 4 provide care to medically underserved populations. They valued the community of peers and colleagues that the NYUBPCP provided. While 53% rated their clinical site as hectic/chaotic (4 or 5 on a 5 point scale), only 6% reported persistently feeling burnout. 19% reported at least one symptom of burnout. Qualitative analyses revealed overlapping themes in alumni perceptions of how residency influenced current practice, aspects of training that were difficult to implement and expectations for the future directions of primary care. Responses demonstrated a mismatch between the "purity" of primary care practice graduates strove to achieve after residency and the actuality of a practice influenced by external factors (e.g. time pressures, reimbursement issues and metric achievements). Some found it difficult to be involved with research or advocacy while in full-time clinical practice. Graduates believed the future of primary care lies in a team-based approach. CONCLUSIONS: A training program emphasizing rigorous curriculum, committed role modeling, care of the underserved, and strong residency community for support continues to document high rates of retention in primary care. They are well adapted entering physicians with the skills and attitudes necessary to succeed in primary care and become educators of the next generation

To date, various dimensions of body image and their associations with condom use have not been studied among men who have sex with men (MSM) who use geosocial-networking smartphone applications ("apps") to meet new sexual partners. The purpose of the current study was to evaluate associations between weight perception, body dissatisfaction, and self-objectification with sexual behaviors among a sample of MSM (n = 92) recruited from Grindr, an app popular among MSM, to complete an online survey. Obese participants scored significantly higher on measures of body dissatisfaction and lower on measures of sexual sensation seeking. Decreased propensities to seek sexual sensations were associated with fewer sexual partners. By assessing associations between dimensions of body dissatisfaction and sexual risk behaviors, this study adds support to a theory of syndemics among MSM, which suggests that synergistically related biological, psychological, social, and behavioral factors disproportionately affect health and health-related behaviors in this population.