Faculty Bibliography

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: 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: Safe, high quality outpatient care often depends on the degree to which patients understand their situation and how to follow through on physician recommendations. However, we do not know enough about how often physicians focus on ensuring that their patients have achieved these understandings by the end of the visit and whether such end-of-visit practices are associated with physicians' communication, patient education and activating skills. METHODS: Two Unannounced Standardized Patient cases (highly trained actors who present as real patients) were delivered to 71 internal medicine residents in two clinics: one required the physician to identify a patient's depression and engage him in follow-up care, and the other required the physician to recognize a patient's failure to use her asthma medicine correctly and educate her in using it properly. End-of-visit practices were: reviewing the plan; asking if further questions; giving information about follow-up care and further contact; and helping the patient navigate the system in order to follow through on next steps. Each was assessed by the SP as not done, partly done, or well done. SPs also rated physicians' communication skills, patient activating skills, and case-specific education skills. Summary scores were calculated as% of items well done. RESULTS: Close to three-quarters of the physicians reviewed the plan with the patient and invited further questions in the depression case and slightly more than half did so in the asthma case (56 and 60%). Patients were given complete information about follow-up care and how to navigate the system in just under half of depression visits (49 and 47%) and just over half of asthma visits (58 and 58%). On average, residents were rated as performing 61% of these 8 items well (SD 28%) across both cases. Primary care residents performed significantly better than categorical internal medicine residents (67%vs 47%, p = .004). There were no differences by physician gender. End of visit scores were significantly positively correlated with both general and casespecific clinical skills, and after controlling for the variance contributed by the program (R2 = 12%, p = .004), case-specific education scores explained 10% of the variance in end of visit score (p = .005), patient activating skills 10% of the variance (p = .002) and communication skills 13% of the variance (p = .001). With all variables in the model, only the general communication domain of patient education and counseling was independently associated with end of visit scores (Std Beta = .35, p = .015). CONCLUSIONS: Had these patients been real patients, in one-quarter to onehalf of the visits, the patient would have left not fully understanding the plan or how to follow-through on care. Resident physicians with more effective communication and patient activating skills tended to provide safer end-of-visit care, suggesting that these may reflect an outpatient safety orientation or skillset

BACKGROUND: Effective smoking cessation counseling improves smokers' health and quality of life. As part of our assessment program, an Unannounced Standardized Patient (USP) case was developed to measure residents' performance in a routine visit with a smoker. METHODS: The USP was a 40 year-old male new patient presenting with heartburn. He began smoking up to two packs/day at 22 years old; at the time of the visit, he reports having cut down to one pack/day and quitting cold turkey twice in the past only to return to smoking. If the resident engages him, he discusses his relationship with smoking and the possibility of quitting. TheUSP received 6 hours of character and checklist training to ensure standardized portrayal and evaluation. Data was collected using 2 forms of assessment: a post-visit USP checklist and a systematic review of the EMR (lab orders, prescriptions, and referrals). The 170- item USP checklist measured communication, patient education, assessment skills, and case-specific items. Each response option included descriptive behavioral anchors and was rated as not done, partly done, or well done. RESULTS: Data was examined from 73 USP visits from 2009-2015. Mean visit length = 37 min, SD = 15 min (range: 15 to 95 min). Overall communication scores ranged from 17 to 100% with an average of 62% (Cronbach's alpha = 0.75). All residents documented History of Tobacco Use or Tobacco Use Disorder in the EMR, and the majority (82%) prescribed smoking cessation medication. There was variation in the sophistication of smoking cessation-counseling approach. Whilemost residents (78%) discussed the risks of smoking and/or the benefits to quitting, significantly fewer (48%) explored the patient's view of the pros and cons of his smoking (p = 0.00). Residents who prescribed smoking cessation medication and discussed risks/benefits to smoking/quitting (N = 31) were compared to residents who did the same but also invited the patient to discuss his personal pros and cons of smoking (N = 29). Groups were not significantly different by PGY or gender. Patients who were asked to discuss their pros/cons rated the resident higher on patient activation questions (0-2 point scale), including "Helped you understand the importance of quitting smoking" (1.38 vs 0.90, p = 0.00), "Made you want to change your smoking" (1.10 vs 0.52, p = 0.00), and "Made you feel like you would be able to quit smoking" (1.07 vs 0.35, p = 0.00). There were no significant differences in labs ordered, referrals to a smoking cessation program, or quality of documentation. CONCLUSIONS: While all residents ask about tobacco use and most appropriately prescribe medication, fewer than half demonstrate the skills known to motivate patients to quit smoking. Curricula needs to reinforce the importance of a patient discussing their personal relationship with smoking in order to feel activated and willing to engage in cessation

BACKGROUND: The Substance Abuse Research and Education Training (SARET) program is funded by the National Institutes of Drug Abuse in 2006 as a novel approach to spark interest in substance abuse research among medical, dental, nursing, and social work graduate students through a Web-based curriculum and research mentorships. This report presents the initial integration of the intervention in a Master of Social Work (MSW) program, the components of the program, and the mixed-methods evaluation of its effect on students' attitudes towards substance abuse research and treatment. METHODS: SARET comprises 2 main components: stipend-supported research mentorships and a Web-based module series, consisting of 6 interactive, multimedia modules addressing core SA research topics, delivered via course curricula and in the research mentorships. An initial evaluation was designed to assess SARET's acceptability and short-term impact on participants' interest in SA research. The components of this Web-based curriculum evaluation include focus group feedback on the relevance of the modules to SW students, number of courses into which the modules were integrated with number of module completions, changes in interest in SA research associated with module completion. RESULTS: The full series of Web-based modules has been integrated across several courses in the social work curriculum, and social work students have become integral participants in the summer mentored research experience. One hundred eighteen students completed at least 1 module and 42 students completed all 6 modules. Neurobiology, Screening, and Epidemiology were the most widely viewed modules. Students reported positive impact on their vision of SA-related clinical care, more positive attitudes about conducting research, and in some cases, change in career. CONCLUSIONS: The SARET program's modules and summer mentored research increased clinical and research interest related to SUDs, as well as interprofessional attitudes among social work students. Participants have shown some early research success. Longer-term follow-up will enable us to continue to assess the effectiveness of the program.

BACKGROUND: Opioid overdose deaths have reached epidemic proportions in the United States. This problem stems from both licit and illicit opioid use. Physicians play a role in prescribing opioids, recognizing risky use, and initiating prevention, including Opioid Overdose Prevention Training (OOPT). The American Heart Association (AHA) modified their basic life support (BLS) algorithms to consider naloxone in high risk populations and when a pulse is appreciated; however, the AHA did not provide OOPT. Our intervention filled this training deficiency by teaching medical students opioid overdose resuscitation with a Train-The-Trainer model as part of mandatory BLS training. METHODS: We introduced OOPT, following a Train-The-Trainer model, into the required Basic Life Support (BLS) training for first-year medical students at a single medical school in a large urban area. We administered pre- and post-evaluations to assess the effects of the training on opioid overdose knowledge, self-reported preparedness to respond to opioid overdoses, and attitudes towards patients with SUDS. RESULTS: In the fall 2014, 120 first-year medical students received OOPT. Seventy-three students completed both pre- and post-training evaluations. Improvements in knowledge about and preparedness to respond to opioid overdoses were statistically significant (p <.01) and large (Cohen's D = 2.70 and Cohen's D = 2.10 respectively). There was no statistically significant change in attitude toward patients with SUDs. CONCLUSIONS: We demonstrated the effectiveness of OOPT as an adjunct to BLS in increasing knowledge about and preparedness to respond to opioid overdoses; improving attitudes toward patients with SUDs likely requires additional intervention. We will characterize knowledge and preparedness durability, program sustainability, and long-term changes in attitudes in future evaluations. These results support dissemination of OOPT as a part of BLS training for all medical students, and potentially all BLS providers.

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

Ureaplasma is a significant cause of nongonococcal urethritis. This is a case of rectal Ureaplasma found on culture in a young man who has sex with men not previously reported in the literature. Nucleic acid amplification tests are now standard of care for sexually transmitted infection testing, but they do not test for Ureaplasma and, therefore, may be missing important infections. Ureaplasma could have important implications in urethritis and rectal HIV transmission among men who have sex with men engaging in condomless anal intercourse. Further study of Ureaplasma's role as a rectal pathogen may be warranted.

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.