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There is a rising number of children with special health care needs (CSHCN) in the pediatric medical home and their care coordination is complicated and challenging. We aimed to integrate nurse care managers to coordinate care for such patients, and then evaluate, if this improved health care utilization.This quality improvement project evaluated the impact on CSHCN of the integration of nurse care managers in the pediatric medical home. From October 2015 through February 2019, 673 children received longitudinal care coordination support from a care manager. Health care utilization for primary, subspecialty, emergency department (ED) and inpatient care was reviewed using pre and post design.Three medical home-based nurse care managers were integrated into four pediatric hospital affiliated practices in a large, urban center. The number of ED visits and inpatient admissions were statistically significantly decreased post-intervention (p 0.05).There was also a decrease in the number of subspecialty visits, but it was close to the threshold of significance (p = 0.054). There was no impact noted on primary care visits.This quality improvement project demonstrates that nurse care managers who are integrated into the medical home of CSHCN can potentially decrease the utilization of ED visits and hospital admissions as well as subspecialty visits.Nurse care managers can play a pivotal role in medical home redesign for the care of CSHCN.

Purpose Most reports of strabismus after glaucoma drainage device implantation study larger devices and rarely note the incidence of strabismus after Ahmed glaucoma valve (AGV) implantation. It is unknown if the pattern of strabismus is similar with smaller devices. We investigated characteristics of strabismus after AGV implantation. Design Retrospective review. Methods Institutional study of 732 patients at our institution undergoing AGV implantation between 2013 and 2018. Rate and characteristics of strabismus were the primary outcome; age, gender, and location of AGVs were also analyzed. Results We identified 29 patients who developed new-onset strabismus postoperatively after initial AGV implantation, for 4% incidence of strabismus. Twenty-one (72%) of these had diplopia. AGVs were implanted superotemporally in 21, superonasally in 5, inferotemporally in 1, and inferonasally in 2. Three patients were esotropic, 11 were exotropic, 4 had hypertropia, 2 had hypotropia, and 9 patients had combined horizontal/vertical strabismus (esotropia/hypotropia [n = 1] or exotropia/hypertropias [n = 8]). Exotropia was the most common type of strabismus in both the superotemporal and superonasal (60%) AGV groups. Superotemporal AGVs were more commonly associated with ipsilateral hypertropia (43%) than superonasal AGVs. Treatments included strabismus surgery (n = 14), prisms (n = 6), or an occlusive lens (n = 1). Discussion. In the largest single-center series of patients undergoing initial AGV implantation, the overall incidence of postoperative strabismus was 4%. This is comparable to strabismus incidence following implantation of other types of glaucoma drainage devices, even larger devices. The possibility of this complication should be discussed with patients prior to surgery.

The current study translated the Resources for Enhancing Alzheimer's Caregiver Health: Offering Useful Treatments (REACH OUT), a skills-building stress and burden intervention, for the primary care setting and pilot the resulting intervention.The 16-week intervention consisted of a combination of clinic-based group and one-on-one sessions offered within a medical home, geriatrics clinic. A quasi-experimental pre- and post-test study design without a control group tested the resulting intervention. Semi-structured qualitative exit interviews evaluated program satisfaction.Twenty-five caregivers participated in one of four intervention groups; 21 caregivers completed the intervention (attended at least five of six group sessions). Caregiver burden on standardized assessments was significantly reduced between pre- and post-intervention, specifically for physical/emotional strain and caregiving uncertainty. Significant reductions were found in the frequency of reported disruptive behaviors; increased caregiver confidence in handling behavior problem frequency, depressive symptoms, disruptive behaviors, and memory-related problems; and decreased bother with respect to behavioral problem frequency and care recipient depression. Program satisfaction was high.This work suggests that the REACH OUT program can be successfully modified for use within a primary-care medical home setting.

To assess interdevice agreement between the iCare IC200 rebound tonometer and Perkins applanation tonometry (gold standard) in a healthy pediatric population.A total of 42 eyes of 42 healthy children were assessed using both tonometers. Data was collected on subject's age, sex, best-corrected visual acuity, and central corneal thickness (CCT). Intraclass correlation coefficient (ICC) and Bland-Altman analyses were used to determine agreement between IC200 and Perkins applanation tonometers. Linear regression analyzed the effects of intraocular pressure (IOP) on device difference.The mean age and standard deviation of healthy pediatric subjects was 10.0 ± 3.3 years. The mean difference between IC200 and Perkins tonometers (IC200-Perkins) was 0.72 mm Hg, with a mean of 17.1 ± 3.0 mm Hg and 16.4 ± 2.5 mm Hg, respectively. The absolute agreement, or ICC, between tonometers was 0.63 (95% CI, 0.56-0.70). Bland-Altman analysis showed 95% limits of agreement ranging from -5.2 to +6.6 mm Hg. CCT was not correlated with IOP for either the IC200 (P = 0.35) or the Perkins tonometer (P = 0.052).Compared to applanation tonometry, IC200 overestimated IOP in healthy children, with a greater frequency of readings+2 mm Hg than-2 mm Hg compared to Perkins. There was moderate agreement between tonometers. CCT was not found to influence IOP measurement for either tonometer.

Problem Medical education academies have been instrumental in providing greater recognition of and promotion for clinician-educators. However, producing education scholarship is essential for clinician-scholar-educator career advancement. Grant funding for education research and protected time to produce scholarship are still lacking for interested physicians, in part due to institutional budget constraints and competing priorities. Approach The Hospital for Special Surgery Academy of Rheumatology Medical Educators was founded in 2011 to promote education scholarship though grants awarded to educators interested in research. Educators were asked to submit proposals aimed at the development of new teaching programs and curricular change. Selected applicants received up to $50,000 per year for one year. Grant money was obtained through directed fundraising from donors. Information from annual grant updates and survey responses from grant recipients in 2017 were used to assess the academy's effectiveness. Outcomes Since 2012, 32 grants have been awarded, totaling $954,045 in funding. Recipients have produced national meeting abstracts, posters, oral presentations, and manuscripts and created unique curricula and electronic learning tools for medical students, residents, fellows, faculty, and patients. Four educators with demonstrated interest and research outcomes were identified during the pilot and received additional funding and support from a dedicated education research assistant. Next steps The academy and the innovation grants program highlight the talents of under-supported and under-recognized teaching faculty by allowing them to distinguish themselves academically as clinician-scholar-educators. The success of these educators emphasizes the clear advantages of a formalized structure to achieve the hospital's education goals. Next steps include providing support for a rheumatology fellow to develop an education research career rather than one in bench, clinical, or translational research.

Background Musician health and wellness, a fundamental requirement for safe, effective and optimal musical performance, is not guaranteed. Performance related musculoskeletal disorders (PRMD) affect between 60% and 90% of all musicians, and have serious consequences on musculoskeletal health, performance ability and the overall healthcare burden of musculoskeletal injury. The high prevalence of PRMD in musicians can be prevented and reduced via health-education programs designed to address risk factors and practice habits. Multiple studies demonstrate the efficacy of education and instructional exercises in reducing PRMD symptoms in musicians. Despite the awareness of risk and the substantial consequence of non-adherence, implementation of health-education programs is complex and challenging and is rarely offered in music institutions. For successful adoption of musculoskeletal health programs, it is important to identify system level barriers and facilitators and it is important to develop and pilot effective strategies to guide successful implementation of musculoskeletal health programs for musicians. Purpose This paper proposes a conceptual framework using implementation science methodology to study the factors that influence adoption of musician health education programs to prevent performance related injury. The overall goal of this methodology is to identify determinants of implementation by engaging key stakeholders, developing strategies for adoption of injury prevention programs and generate hypotheses for future studies. Methods The research plan is designed to accomplish the specific aims of this study. Through a mixed-method study we will use qualitative and quantitative methods to address potential barriers, and design and test implementation feasibility of health-education programs for musicians. Results/Conclusions Our findings will inform the development of a large-scale participant randomized hybrid trial to assess effectiveness and implementation outcomes of health education programs and ultimately reduce injury and promote musculoskeletal longevity and performance in musicians

Introduction: In the setting of COVID-19, pediatric primary care in New York City faced multiple challenges, requiring large-scale practice reorganization. We used quality improvement principles to implement changes to care delivery rapidly. Methods: Plan-do-study-act cycles were used, based on primary drivers of consolidation, reorganization of in-person and urgent care, telehealth expansion, patient outreach, mental health linkages, team communication, and safety. Results: The average visit volume in pediatrics decreased from 662 per week to 370. Telehealth visits increased from 2 to 140 per week, whereas urgent in-person visits decreased from 350 to 8 per week. Adolescent visits decreased from 57 to 46 per week. Newborn Clinic visits increased from 37 per week to 54. Show rates increased significantly for pediatrics and adolescent (P = 0.003 and P = 0.038, respectively). Conclusions: Quality improvement methodology allowed for the consolidation of pediatric primary care practices during the first wave of the COVID-19 pandemic, ensuring care for patients while prioritizing safety, evidence-based practices, and available resources.

Background Nearly all pediatric patients in our setting meet high-risk criteria for lead exposure based on screening recommendations and guidelines. Implementation of screening and testing has been inconsistent. Objective To assess the utility and efficacy of performing universal lead testing between ages 1 and 5 at an urban academic pediatric practice. Methods Retrospective review of patients with routine lead testing between 2010 and 2015. Key variables included demographics, serum lead level, and behavioral diagnoses. Results A total of 6597 serum lead levels from 3274 patients were reviewed. Forty-seven samples (0.7%) from 24 patients (0.7%) were elevated. Of the 24 patients with elevated lead, 75% were identified at age 1 or 2. Sixty-seven percent of patients with first elevated lead level at age 3 or older had a diagnosis of developmental delay. Conclusion Routine testing of high-risk patients yielded minimal specificity in identifying elevated lead levels, especially in patients older than 3 years and without developmental delay.

Background: The COVID-19 pandemic resulted in significant uncertainty and disruption to many aspects of daily living, including physical activity, socialization opportunities, and access to healthcare services. Under these conditions, at-risk older adults are even more likely to be inactive and isolated, leading to potential exacerbation of musculoskeletal and chronic conditions and emotional distress. This case study provides an overview of our experience and best practices developed during our shift from onsite programming to virtual.Methodology: HSS utilized varied online approaches, including phone/video conference classes, webinars, on-demand videos and email campaigns to successfully transition programs. Due to this shift, HSS changed its evaluation to an online approach, using a mixed method to adequately assess the impact of programs.Results: Between April and August 2020, our virtual programs reached 428,766 participants, resulting in a 10,807% increase in program reach. Most participants assessed were 60 years or older (72%) and reported knowledge (85%) and self-management skills (83%) gained as well as high program satisfaction (90%). Analyses of program data did not show any statistical significant difference in self-reported health outcomes. However, qualitative results showed virtual programming helped to foster social connectivity during COVID-19, helped to build a daily routine, and positively impacted mental and physical health.Conclusion: Shifting to virtual programming in the face of the pandemic enabled us to deliver effective programs affording our community the opportunity to stay physically active and socially connected despite the quarantine orders.

During the height of the COVID-19 pandemic, telemedicine visits surged to increase access and maintain continuity of care, while reducing transmission of disease. However, few curricula exist for training residents on how to care for patients via telemedicine, especially in pediatrics. We aimed to create and evaluate an interactive, competency-based pilot curriculum, to meet the urgent need to train residents in telemedicine. The curriculum was developed in 2020 and includes a didactic, cased-based discussions, and direct observation exercise. A model for precepting residents, adhering to new ACGME guidelines, was also created to further engage residents in telemedicine in the outpatient general pediatrics settings. To evaluate the curriculum, we assessed feasibility of a direct observation to provide feedback and we conducted pre and post surveys to assess for changes in residents’ self-reported skills in performing telemedicine visits following implementation of the curriculum. 16 residents participated in the curriculum and 15 completed both the pre and post surveys (93%). Residents’ self-reported efficacy in performing key components of telemedicine visits, including completion of telemedicine visit (p = 0.023), initiation of visits (p = 0.01), and documentation (p = 0.001) all improved significantly following implementation. Residents’ perception of patient satisfaction with telemedicine and personal perception of ease of use of the telemedicine system increased, though neither were statistically significant. Uptake of the direct observation exercise was nearly universal, with all but one resident having a direct observation completed during their ambulatory month. This novel, interactive telemedicine pilot curriculum for residents addresses ACGME competencies and provides residents with a toolkit for engaging in telemedicine.

Background: Multidisciplinary team mentoring increasingly is being advocated for biomedical research training. Before implementing a curriculum that could include team mentoring, we asked faculty about their opinions of this mentoring approach. Questions/Purposes: The goals of this study were to ask faculty about the benefits, challenges, and drawbacks of team mentoring in research training. Methods: Twenty-two experienced mentors representing all academic departments at a single institution were interviewed about perceived benefits, drawbacks, and their willingness to participate in team mentoring. Responses were analyzed with qualitative techniques using grounded theory and a comparative analytic strategy. Results: Faculty noted academic pursuits in medicine usually occur within, and not across, specialties; thus, multidisciplinary team mentoring would require coordinating diverse work schedules, additional meetings, and greater time commitments. Other challenges included ensuring breadth of expertise without redundancy, skillfully managing group dynamics, and ensuring there is one decision-maker. Potential drawbacks for mentees included reluctance to voice preferences and forge unique paths, perceived necessity to simultaneously please many mentors, and less likelihood of establishing a professional bond with any particular mentor. Conclusions: Faculty recommended caution before embracing team mentoring models. An acceptable alternative might be a hybrid model with a primary mentor at the helm and a selected group of co-mentors committed to a multidisciplinary effort. This model requires training and professional development for primary mentors.

Background Dental caries are the most common chronic condition of childhood and have significant medical, psychological, and financial consequences. The American Academy of Pediatrics (AAP) recommends primary care physicians apply fluoride varnish (FV) every 3 to 6 months from tooth emergence through age 5. Objective Through a resident-led quality improvement (QI) project, we aimed to provide FV to 50% of patients ages 1 through 5 who did not have a dental visit in the preceding 6 months or receive FV elsewhere in the past month. Methods From May 2017 through April 2018, we conducted 7 monthly plan-do-study-act cycles to improve our primary outcome measure (FV application), secondary outcome measure (percentage of patients who had routine dental care), and process measure (percentage of dental referrals). Balancing measures included time taken away from other clinical priorities and reimbursement rates. Results Fluoride varnish application improved from 3.6% to 44% with a 54% peak. The percentage of patients under 6 who had seen a dentist in the past 6 months increased from 30% to 47%. The percentage of dental referrals increased from 17% to 33%. Conclusions Application of FV is a quick, cost-effective way for primary care providers to improve dental health. This resident-led QI project increased rates of FV application, dental referrals, and dental visits while meeting ACGME guidelines for experiential learning in QI. By adapting to state-specific guidelines and workflows of each clinic, this QI project could be nationally reproduced to improve adherence to AAP and United States Preventive Services Task Force guidelines.

The published article contained four sentences with incorrect reference citations. Here, those sentences and the reference list are corrected.

Purpose Selection of the ideal procedure to correct symptomatic excyclotropia depends on several factors including the degree of torsion and associated vertical, horizontal and pattern deviation. Selective tuck of the anterior temporal torsional fibers of the superior oblique (SO) tendon is an alternative procedure to the classical Harada-Ito. The purpose of this study is to report its stability and results. Methods Retrospective review of all consecutive patients with symptomatic excyclotorsion of at least 5o (degrees) treated by selectively splitting and tucking the anterior temporal fibers of the SO tendon. Torsion in primary position was measured using the double Maddox Rods. Patients with additional symptomatic vertical or horizontal diplopia underwent simultaneous surgery on other extraocular muscles. Results Five patients were studied. Mean age was 60 ± 8 years (47-67). Mean postoperative follow-up was 10 ± 8 months (3-21). The mean preoperative torsion of 11o±4o (7o-15o) significantly decreased to 3o±2o (p = .03) at the first postoperative visit (16 ± 9 days) and 3 ± 2o during the last visit (P = .03). The procedure corrected 1.4o±0.9o per mm of tuck. Postoperatively no patient complained of torsion. No undesirable vertical or horizontal deviations were noted. Conclusion This technique is a simple alternative to manage symptomatic excyclotorsion, with significant and stable relief of moderate amounts of torsion and without inducing unexpected vertical or horizontal deviation.

Background It is vital for physicians and surgeons to communicate successfully with older adults, who will constitute one-fifth of the US population by 2030. Older adults often perceive themselves as stigmatized and powerless in healthcare settings. Effective communication leads to better patient compliance and satisfaction, which is now a component of Medicare hospital reimbursement and physician and surgeon compensation from hospitals and networks. Objective To increase orthopaedic surgery resident understanding of the unique needs of older adults in order to maintain effective and sensitive communication with this vulnerable population. Design A two-part training program (ongoing for 8 years) comprised of: 1) small-group interactive didactic sessions on aging issues; and 2) workshop demonstrations given by the residents to a group of older adults, followed by a Question & Answer session. Residents were assessed using a 22-item pre–post questionnaire covering medical knowledge of aging, attitudes toward older adults, and personal anxiety about aging. Older adult participants were surveyed for perceptions of residents’ sensitivity toward them. Setting Hospital for Special Surgery in New York City, a specialized urban academic center, with a 5-year Orthopedic Surgery Residency program. Participants 70 PGY3 residents, for whom the program is a requirement, and 711 older adult participants recruited from a community convenience sample. Results Older adult participants: Of 711 participants, 672 (95%) responded; 96% strongly agreed/agreed that the residents had demonstrated sensitivity toward them. Residents: Of 70 residents, 35 (50%) were assessed. Mean knowledge scores increased significantly (p ≤ 0.001); five of nine attitude items (p ≤ 0.05) and one of four anxiety items improved significantly (p ≤ 0.001). Conclusions Significant change was seen in residents’ attitudes and anxiety levels toward older adults, attributes that are usually deep seated and hard to change. Residents moved along the Accreditation Council for Graduate Medical Education Milestones continuum for three core competencies.

Background: Immune thrombocytopenia (ITP) is characterized by isolated low platelet count in the absence of other etiologies for thrombocytopenia. Despite published guidelines (Neunert, Blood Adv 2019), controversy exists in the management of patients with pediatric refractory ITP. Data on second-line treatment approaches is limited and no randomized controlled trials exist for this patient group. A comparative-effectiveness trial demonstrated variation in prescribing practices, with parental or patient preference involved in decision making in 55% of cases (Grace, Am J Hematol, 2018). Despite this data, no qualitative studies have been done to explore the patient experience. We aim for the first time to explore thematic areas surrounding rationale for treatment choice for patients with refractory ITP from the patient/parent point of view, as a first step to creating a decision aid. Our goal is that this aid will inform individuals with regards to options, encourage engagement of patients in decision, and assist patients with processing their preferences so they can make choices reflective of their values. Methods: Purposeful sampling identified participants locally from Columbia University Medical Center as well as nationally through the Platelet Disorder Support Association. Focus groups were conducted with an average of 5-7 parents of children with ITP in each group, and each lasting approximately 90 minutes. A written guide with open-ended questions was created to elicit participant opinions and foster guided discussion between them, illuminating particular concepts and permitting researchers to gain an understanding of patient experiences in the context of their own lives. Focus groups were audio recorded and transcribed. The de-identified transcripts were uploaded into Dedoose, a qualitative software. A thematic analysis was conducted to identify the nature, strength and prevalence of key concepts. Results: Three major themes were identified with regards to treatment choice for second line therapy: 'Experiences with Treatment Decision Making', 'Factors Important in Decision Making', and 'Concept of Remission'. Excerpts demonstrating findings from each theme, as well as some of the variability amongst participants' opinions, are shown in Table 1. With regards to experiences with treatment decision making, many parents expressed that they felt their hematologist presented the options with adequate descriptions of risks and benefits, though the extent to which parents seem to feel included in the decision was not consistent. Often, even if presented with options, parents did not view themselves as critical decision makers and some patients still reported not feeling well-educated about options. Additionally, many participants reported that they went through a "trial and error" process with regards to different second-line therapies, with no notable or specific conversations defining any one person's experience. Discussion: The data collected suggests that parents of children with refractory ITP have strong ideas about communications around their treatment options. The factors important to decision making appeared consistent between participants, and would provide valuable input in the ultimate decision making tool and also be important to capture in future research trials of different agents. Of interest, the concept of remission came up frequently, and did not have the meaning that the research team expected. Participants noted that the term had a negative connotation, and meant only that there was a possibility of the disease returning. They felt that the term gave a false sense of relief, because their disease was unlikely to be truly cured. This was emphasized as a value in treatment selection. The information provided by these focus groups indicates that physicians' views on choosing therapies "based on patient preference" are not completely aligned with the patient experience. Additional focus group work, creation of a patient decision-aid, and inclusion of patient relevant outcomes in research will hopefully close this gap. We ultimately hope to create a clinical decision aid developed from input of these focus groups in order to increase patient understanding of their options, improve targeted treatment effects with regards to patient-related outcomes of importance, and help to guide management decisions. Disclosures Neunert: Platelet Disorder Support Association: Research Funding.

PURPOSE: Sagging eye syndrome (SES), horizontal and/or vertical strabismus caused by orbital connective tissue degeneration, was first defined 10 years ago. In this study, we investigated the causes of acquired binocular diplopia in adults presenting to single institution since the description of SES. DESIGN: Retrospective observational case series. METHODS: We reviewed medical records of all new patients over age 40 years who presented to the Stein Eye Institute with binocular diplopia between January 2015 and December 2018. We tabulated clinical causes of diplopia in patients grouped by age and gender. In patients with SES, we tabulated binocular alignment, types of treatment, and surgical outcomes. RESULTS: There were 945 patients of mean age 66.5 years, of whom 514 (54.4%) were female. The most common cause of diplopia was SES (31.4%). The 297 patients with SES were older at 71.2 years (p

OBJECTIVES: To examine whether patients with multisystem inflammatory syndrome in children (MIS-C) demonstrated well-defined clinical features distinct from other febrile outpatients, given the difficulties of seeing acute care visits during the severe acute respiratory syndrome coronavirus 2 pandemic and the risks associated with both over- and underdiagnosis of MIS-C. STUDY DESIGN: This case-controlled study compared patients diagnosed with and treated for MIS-C at a large urban children's hospital with patients evaluated for fever at outpatient acute care visits during the peak period of MIS-C. Symptomatology and available objective data were extracted. Comparisons were performed using t tests with corrections for multiple comparisons, and multivariable logistic regression to obtain ORs. RESULTS: We identified 44 patients with MIS-C between April 16 and June 10, 2020. During the same period, 181 pediatric patients were evaluated for febrile illnesses in participating outpatient clinics. Patients with MIS-C reported greater median maximum reported temperature height (40°C vs 38.9, P

Introduction Children with special health care needs (CSHCN) are a high risk population with complex medical issues and needs. It is challenging to care for them in a busy, pediatric practice without understanding how many exist and how best to allocate resources. EMRs can be adapted to develop registries and stratify patients to promote population health management. Methods Adaptations were made to the EMR in September 2013 to capture CSHCN and the associated risk level during well-child visits prospectively. All physicians were trained on the definition of CSHCN and on risk stratification levels 1, 2, 3A and 3B. An analysis using one-way ANOVA for children ages 0–21, seen between September 1, 2011 and August 31, 2015, who were identified and stratified after September 2013, was conducted to determine utilization patterns on hospital admissions, emergency department (ED), subspecialty, and primary care visits. Results A total of 4687 CSHCN were identified during the study period. Of the CSHCN, 45% were Level 1, 41% Level 2, 7% 3A and 7% 3B. There were significant differences in utilization across the tiers of CSHCN with the highest level of stratification (3B) demonstrating the most hospital admissions and primary care visits. Level 3B and level 3A (unstable) had significantly more ED visits. Additionally, as tiers increased from level 1 to 3B there was an increase in subspecialty provider utilization (p

INTRODUCTION Continuing education is necessary to foster new and effective research mentoring skills. We asked faculty about their research mentoring practices and what would support their skills and abilities as ongoing and effective research mentors. METHODS Twenty-two experienced mentors were interviewed and asked about perceived areas for improvement, and challenges and facilitators to continued research mentoring. Responses were analyzed with qualitative techniques using semistructured interviews, grounded theory, and a constant comparative analytic strategy. RESULTS The average time since the completion of the doctoral degree was 26 years. Twenty-one participants believed that more comprehensive institutional acknowledgment for their efforts would enhance research mentoring. This specifically included acknowledging their time spent and service (ie, effort) in multiple in-person and behind-the-scenes tasks. These research mentoring efforts were largely viewed as overlooked by the traditional focus on the achievement of tangible outcomes. Participants thought that a formal plan to organize research mentoring (such as a mentor's charter, and continuing education tailored to both novice and experienced research mentors) was needed to promote evolution of skills and documentation of time and service. Possible methods to support research mentors were suggested and included financial support for travel to national meetings, assistance in developing new projects, and consideration of mentoring activities in the process for academic promotion. DISCUSSION Research mentors wanted their achievements, time spent, and service (ie, effort) to be acknowledged by the institution. A formal written mentoring charter and corresponding continuing education could facilitate acknowledging achievements, time, and service and thus help to sustain academic research mentoring.

BackgroundHome care workers (HCWs) increasingly provide long‐term and posthospitalization care for community‐dwelling adults with heart failure (HF). They observe, assist, and advise these patients, yet few studies have examined their role inHF. As the foundation for future interventions, we sought to understand the perspectives ofHCWs caring for adults withHF.Methods and ResultsWe conducted 8 focus groups in partnership with the Home Care Industry Education Fund, a benefit fund of the 1199 Service Employees International Union United Healthcare Workers East, the largest healthcare union in the United States. English‐ and Spanish‐speakingHCWs withHFclients were eligible to participate. Data were analyzed thematically. Forty‐sixHCWs employed by 21 unique home care agencies participated. General andHF‐specific themes emerged. Generally,HCWs (1) feel overworked and undervalued; (2) find communication and care to be fragmented; (3) are dedicated to clients and families but are caught in the middle; and, despite this, (4) love their job. With respect toHF,HCWs (1) find it frightening and unpredictable; (2) are involved inHFself‐care without anyHFtraining; and (3) find the care plan problematic.ConclusionsAlthough frequently involved inHFself‐care, mostHCWs have not receivedHFtraining. In addition, many felt poorly supported by other healthcare providers and the care plan, especially when their clients’ symptoms worsened. Interventions that provideHF‐specific training and aim to improve communication between members of the home health care team may enhanceHCWs’ ability to care for adults withHFand potentially lead to better patient outcomes.

ObjectiveTo examine the perspectives of adults with heart failure (HF) about numerical concepts integral to HF self-care.SettingThis qualitative study took place at an urban academic primary care practice.ParticipantsThirty men and women aged 47–89 years with a history of HF were recruited to participate. Eligibility criteria included: a history of HF (≥1 year), seen at the clinic within the last year, and a HF hospitalisation within the last 6 months. Non-English speakers and those with severe cognitive impairment were excluded.MethodsIn-depth semistructured interviews were conducted. Participants were interviewed about numeracy across three domains of HF self-care: (1) monitoring weight,(2) maintaining a diet low in salt and (3) monitoring blood pressure. Interviews were audio-taped, transcribed verbatim and analysed using grounded theory and word cloud techniques.ResultsFive key themes reflecting participants’ attitudes towards numerical concepts pertaining to weight, diet and blood pressure were identified: (1) Communication between healthcare providers and patients is a complex, multistage process; (2) Patients possess a wide range of knowledge and understanding; (3) Social and caregiver support is critical for the application of numerical concepts; (4) Prior health experiences shape outlook towards numerical concepts and instructions and (5) Fear serves as a barrier and a facilitator to carrying out HF self-care tasks that involve numbers. The findings informed a theoretical framework of health numeracy in HF.ConclusionEffective communication of numerical concepts which pertain to HF self-care is highly variable. Many patients with HF lack basic understanding and numeracy skills required for adequate self-care. As such, patients rely on caregivers who may lack HF training. HF-specific training of caregivers and research that seeks to elucidate the intricacies of the patient–caregiver relationship in the context of health numeracy and HF self-care are warranted.

Background: Paid home care workers (HCWs) represent one of the fastest growing sectors of the US workforce and healthcare industry. They are increasingly utilized by home-dwelling adults with heart failure (HF) for long term assistance and post-acute care. Yet, little is known about the perspectives of HCWs regarding their role in HF management and as part of the healthcare team. Objective: We sought to understand the perspectives of HCWs who take care of adults with HF as the foundation for the development of future intervention(s). Methods: We conducted 8 focus groups with English and Spanish-speaking HCWs at the 1199SEIU’s Home Care Industry Education Fund, a non-profit organization that oversees the training of 65,000 HCWs from 50 home care agencies across NYC. Eligibility criteria included taking care of a client with HF within the last year and being a HCW for at least 2 years. Purposeful sampling ensured equal representation of English and Spanish speaking HCWs. Focus groups were audio recorded and professionally transcribed. Data were organized using qualitative software and analyzed using grounded theory. Results: The 46 participants were mean age of 49 years (SD 10), 45 (98%) were female, 17 (37%) were Black, 25 (54%) were Hispanic, and 42 (91%) had at least a high school education. Participants had been HCWs for 16 years (8.4 SD) and spent 3.5 days per week (1.8 SD) with HF clients. Seven major themes emerged: 1. HF has an unpredictable disease course, which is frightening to HCWs. “One minute we’re watching TV and the next, he crumps.” 2. HCWs often assist with HF management , although most have not received HF training. “Over time, you pick up on the symptoms - the shortness of breath, the swollen legs. But, I’ve never received HF training.” 3. Communication is fragmented. ?No one at the agency picks up the phone, so I just take him to the emergency room instead.? 4. HCWs are ignored by the healthcare team. “We’re with the clients all day, more than anyone else. So why aren’t we included in the conversation?” 5. Role definition is lacking . “The agency doesn’t make clear who we are or what we do. We aren’t just the help!” 6. Delicate family dynamics. “I’m always in the middle and I can’t afford to lose my job.” 7. Social isolation and burnout. “I’m with her all day, and she has Dementia too. It’s hard -- I’ve literally got nobody to talk to.” Conclusions and Implications: Our findings suggest that while HCWs are frequently involved in their clients’ HF management, most have not received formal HF training or resources. Additionally, despite spending so much time caring for their clients, they often feel invisible to healthcare providers. HF-specific training, as well as interventions that aim to integrate HCWs into the healthcare team, may improve HCWs’ HF knowledge and the quality of care delivered to adults with HF.

Arthritis and other musculoskeletal diseases are the most prevalent health conditions in the USA, causing enormous financial and social burdens, especially in underserved communities. Targeted care and prevention programs are urgently needed.Within an overall goal of revealing health disparities, the questionnaire explored (1) the use of and access to healthcare, (2) the factors affecting quality of life, and (3) the levels of provider-patient communication.A New York City musculoskeletal hospital conducted a community health needs survey among its diverse ethnic/racial communities. A 39-item questionnaire was administered online, by mail, and in person (in English, Spanish, and Chinese). Answers were analyzed in terms of sociodemographics, to define health disparities within a total sample and two subsamples.In the total sample, respondents were 60% White, 16% Black, 14% Hispanic/Latino, and 11% Asian, mostly female, and aged 50 to 79. More than 17% of the total sample indicated they could not access a healthcare provider when needed. Poor nutrition and lack of physical activity were large areas of concern, as were falls and poor self-reported health status. Nearly all respondents said they took steps to communicate with their healthcare providers. Dramatic health disparities were found between Whites and non-Whites (e.g., non-Whites were most likely to rate their health poorly, consider their diet fair or poor, lack health insurance, and be unable to access a healthcare provider).The findings are being used to further refine, develop, and expand the hospital's community programs, especially for culturally diverse and underserved communities.

Older adults often perceive themselves as stigmatized and powerless in healthcare settings. Communication with them is complicated by age-related issues and negative stereotypes about older adults and aging. It is therefore vital for physicians and surgeons, who encounter the most vulnerable elderly, to communicate successfully with this population, who wish to maintain quality and dignity in their lives. Successful patient communication leads to better recall of information, compliance, adherence to medications, satisfaction, and overall better outcomes. We developed a two-part training program comprised of small group interactive didactic sessions on aging issues with third year surgical residents, and workshop demonstrations given by the residents to a group of older adults, followed by a question and answer session. Residents were assessed using a 22-item pre–post questionnaire covering medical knowledge of aging, attitudes toward older adults, and personal anxiety about aging. Since its inception, the program has reached 88 residents and 711 older adults. For residents, knowledge scores (p ≤ 0.001), six of nine attitude items (p ≤ 0.01) and one of four anxiety items (p ≤ 0.001) improved significantly. This is notable as well since attitudes and anxiety levels are attributes that are deep-seated and hard to change. For older adults, post surveys showed that 96% strongly agreed/agreed that residents had demonstrated sensitivity toward them and 96% were very satisfied/satisfied with the program. Our replicable, low-cost program enables residents to learn and realistically practice universal underlying communication skills in order to maintain effective and sensitive communication with this vulnerable population.

Background: Although relatively uncommon, neurological deficits following hip and knee arthroplasty can have permanent and debilitating consequences. This study was conducted to quantify the effectiveness of an educational curriculum aimed at standardizing the identification of and acute response to postoperative neurological deficits in the inpatient setting, specifically with respect to improvements in clinician knowledge, confidence levels, and communication skills. Methods: A multidisciplinary committee at a single, high-volume academic institution created an algorithm delineating the appropriate clinical actions and escalation procedures in the setting of a postoperative neurological deficit for each clinical practitioner involved in care for patients who undergo arthroplasty. An educational curriculum composed of online learning modules and an in-person “boot camp” featuring simulations with standardized patients was developed, along with assessments of clinician knowledge, confidence levels, and communication skills. Nurses, physical therapists, physician assistants, residents, fellows, and attending surgeons were encouraged to participate. The intervention spanned a 5-month period in 2015 with a mean time of 18.4 weeks between baseline assessments and the time of the latest follow-up. Results: Online modules were completed by 322 individuals, boot camp was completed by 70 individuals, and latest assessments were completed by 38 individuals. The percentage correct on the knowledge assessment increased from 74.5% before the learning modules to 89.5% immediately after (p < 0.001) but degraded over time such that there was no significant difference between baseline and the latest follow-up scores (p = 0.11). Over the course of the boot camp, physician assistants and residents successfully performed approximately 91% of the indicated actions on the scoring rubric; physical therapists and nurses successfully performed 78%. Scores on the communication skills assessment showed a significant mean increase (p = 0.02) over the course of the intervention from 30.32 to 32.50, and the mean self-assessed confidence survey scores increased by 16.7%, from 7.2 to 8.4 (p < 0.001). Conclusions: A multimodality educational curriculum aimed at quality improvement can produce significant knowledge improvements, but these gains may not be maintained over time without further instruction. Gains in confidence and communication skills appear to be more long-lasting.

Objective Relatively little attention has been devoted to the role of communication between physicians as a mechanism for individual and organisational learning about diagnostic delays. This study’s objective was to elicit physicians’ perceptions about and experiences with communication among physicians regarding diagnostic delays in cancer. Design, setting, participants Qualitative analysis based on seven focus groups. Fifty-one physicians affiliated with three New York-based academic medical centres participated, with six to nine subjects per group. We used content analysis to identify commonalities among primary care physicians and specialists (ie, medical and surgical oncologists). Primary outcome measure Perceptions and experiences with physician-to-physician communication about delays in cancer diagnosis. Results Our analysis identified five major themes: openness to communication, benefits of communication, fears about giving and receiving feedback, infrastructure barriers to communication and overcoming barriers to communication. Subjects valued communication about cancer diagnostic delays, but they had many concerns and fears about providing and receiving feedback in practice. Subjects expressed reluctance to communicate if there was insufficient information to attribute responsibility, if it would have no direct benefit or if it would jeopardise their existing relationships. They supported sensitive approaches to conveying information, as they feared eliciting or being subject to feelings of incompetence or shame. Subjects also cited organisational barriers. They offered suggestions that might facilitate communication about delays. Conclusions Addressing the barriers to communication among physicians about diagnostic delays is needed to promote a culture of learning across specialties and institutions. Supporting open and honest discussions about diagnostic delays may help build safer health systems.

While most faculty members want to improve as teachers, they neither know where their educational strengths and weaknesses lie nor where or how to begin to effect a change in their teaching abilities. The lack of actionable, directed and specific feedback, and sensible and sensitive metrics to assess performance and improvement complicates the attainment of educational excellence.The purpose of this article was to outline a series of specific steps that medical education programs can take to enhance the quality of teaching, promote teaching excellence, elevate the status and value of medical educators, and stimulate the creation of innovative teaching programs and curricula.To achieve these goals at the Hospital for Special Surgery, the Academy of Rheumatology Medical Educators was formed. The academy had the following goals: (1) create within our institution a mission which advances and supports educators, (2) establish a membership composed of distinguished educators, (3) create a formal organizational structure with designated leadership, (4) dedicate resources that fund mission-related initiatives and research, and (5) establish a plan for promoting teachers as well as enhancing and advancing educational scholarship.The Hospital for Special Surgery Academy of Rheumatology Medical Educators was recently formed to address these goals by promoting teaching and learning of musculoskeletal skills in an environment that is supportive to educators and trainees and provides much needed resources for teachers.The development of a pilot academy of medical educators represents one of the high-priority goals of those institutions that wish to elevate and enrich their teaching through a structured, proven approach.

The International Society of Orthopaedic Centers was formed in 2006 as a think tank that would bring together thought leaders in orthopaedic surgery from major orthopaedic academic centers around the world. The Society’s mission is to share knowledge and strategies, improve patient care, and foster clinical, educational, and scientific collaboration. As the Society’s agendas developed, the members recognized that many of their aims intersected with those of hospital leadership. Thus, CEOs from member centers were invited to join their physician colleagues at the 2010 meeting in Bologna, Italy in order to explore solutions to administrative challenges related to patient care, volume growth, and costs. This paper describes the dialogue that took place at the meeting.

Objective To document values, attitudes, and beliefs that influence behavior change among a diverse group of patients post-angioplasty. Methods Purposive and maximum-variation sampling were used to assemble a demographically diverse patient cohort (N = 61) who had been successful or unsuccessful at post-angioplasty multibehavior change. Semistructured interviews and grounded theory methods were used to collect and analyze qualitative data. Results Themes showed the following: a) Patients reported surviving a life-threatening event and feared disease recurrence and death; b) the perception of a turning point and self-determination facilitated behavior change; c) social support and spiritual beliefs promoted coping with the uncertainty of living with heart disease; and d) unsuccessful behavior change was related to physical limitations, a sense that “nothing helps,” and the belief that angioplasty “cures” heart disease. Conclusion Lifestyle interventions should be culturally relevant and adapted to physical abilities. Fostering self-determination and social support may promote successful behavior change.

This article describes the development of an interactive self-management workbook to increase asthma knowledge and self-efficacy. Its format encourages readers to write in their own personal experiences and perspectives. The knowledge component was developed from standard materials and organized into thematic chapters. The self-efficacy component was developed from interviews with patients in the outpatient setting, emergency room, and hospital; it consists of three sections explaining why confidence is necessary to be an effective self-manager and offers techniques to increase confidence. The component’s cornerstone is vignettes of patients describing what triggers their asthma and what behaviors they use to successfully manage it. This novel approach to fostering self-efficacy allows patients to see themselves in others’ success stories. Although not a substitute for self-management courses, the workbook promotes self-management by offering a practical and readily available option to in-person instruction and peer contact, which are accessible to only a small number of patients.