A Resident-Led Intervention to Increase Initiation of Buprenorphine Maintenance for Hospitalized Patients With Opioid Use Disorder.

BACKGROUND: Hospitalized patients with opioid use disorder (OUD) are rarely started on buprenorphine or methadone maintenance despite evidence that these medications reduce all-cause mortality, overdoses, and hospital readmissions. OBJECTIVE: To assess whether clinician education and a team of residents and hospitalist attendings waivered to prescribe buprenorphine increased the rate of starting patients with OUD on buprenorphine maintenance. DESIGN, SETTING, AND PARTICIPANTS: Quality improvement study conducted at a large, urban, academic hospital in Maryland involving hospitalized patients with OUD on internal medicine resident services. INTERVENTION: We developed a protocol for initiating buprenorphine maintenance, presented an educational conference, and started the resident-led Buprenorphine Bridge Team of residents and attendings waivered to prescribe buprenorphine to bridge patients from discharge to follow-up. MEASUREMENTS: The percent of eligible inpatients with OUD initiated on buprenorphine maintenance, 24 weeks before and after the intervention; engagement in treatment after discharge; and resident knowledge and comfort with buprenorphine. RESULTS: The rate of starting buprenorphine maintenance increased from 10% (30 of 305 eligible patients) to 24% (64 of 270 eligible patients) after the intervention, with interrupted time series analysis showing a significant increase in rate (14.4%; 95% CI, 3.6%-25.3%; P = .02). Engagement in treatment after discharge was unchanged (40%-46% engaged 30 days after discharge). Of 156 internal medicine residents, 89 (57%) completed the baseline survey and 66 (42%) completed the follow-up survey. Responses demonstrated improved resident knowledge and comfort with buprenorphine. CONCLUSION: Internal medicine resident teams were more likely to start patients on buprenorphine maintenance after clinician education and implementation of a Buprenorphine Bridge Team.

Longitudinal resident coaching in the outpatient setting: A novel intervention to improve ambulatory consultation skills.

BACKGROUND: Direct observation with feedback to learners should be a mainstay in resident education, yet it is infrequently done and its impact on consultation skills has rarely been assessed. APPROACH: This project presents the framework and implementation of a longitudinal low-frequency, high-intensity direct observation and coaching intervention, and elaborates on insights learned. Internal medicine interns at one residency training program were randomized to an ambulatory coaching intervention or usual precepting. Over one year, coached interns had three complete primary care visits directly observed by a faculty clinician-coach who provided feedback informed by a behavior checklist. Immediately after each of the coached patient encounters, interns completed a structured self-assessment and coaches led a 30-minute feedback session informed by intern self-reflection and checklist items. Interns with usual precepting had two mini-CEX observations over the course of the year without other formal direct observation in the ambulatory setting. EVALUATION: As part of the post-intervention assessment, senior faculty members blinded to intervention and control group assignments evaluated videotaped encounters. Coached interns completed an average of 21/23 behaviors from the checklist, while interns from the control group completed 18 (p < 0.05). The median overall grade for coached interns was B+, compared to B-/C+ for controls (p < 0.05). REFLECTION: Coaching interns longitudinally using a behavior checklist is feasible and associated with improved consultation performance. Direct observation of complete clinical encounters followed by systematic coaching is educationally valuable, but time and resource intensive.

Outcomes of a novel office-based opioid treatment program in an internal medicine resident continuity practice.

BACKGROUND: The integration of opioid use disorder (OUD) care and competencies in graduate medical education training is needed. Previous research shows improvements in knowledge, attitudes, and practices after exposure to OUD care. Few studies report outcomes for patients with OUD in resident physician continuity practices. METHODS: A novel internal office-based opioid treatment (OBOT) program was initiated in a resident continuity clinic. Surveys of resident and staff knowledge and attitudes of OBOT were administered at baseline and 4 months. A retrospective chart review of the 15-month OBOT clinic obtained patient characteristics and outcomes. RESULTS: Twelve patients with OUD were seen in the OBOT clinic. Seven patients (58%) were retained in care at the end of the study period for a range of 9-15 months. Eight patients demonstrated a good clinical response. Surveys of residents and staff at 4 months were unchanged from baseline showing persistent lack of comfort in caring for patients with OUD. CONCLUSIONS: OBOT can be successfully integrated into resident continuity practices with positive patient outcomes. Improvement in resident and staff attitudes toward OBOT were not observed and likely require direct and frequent exposure to OUD care to increase acceptance.

Coaching Residents in the Ambulatory Setting: Faculty Direct Observation and Resident Reflection.

BACKGROUND: Direct observation can be valuable for learners' skill development in graduate medical education, but it is done infrequently. Information on how to optimize trainee learning from, and best practices of, direct observation interventions in the ambulatory setting is limited. OBJECTIVE: We explored the impact of a focused outpatient direct observation and coaching intervention on internal medicine residents. METHODS: Using a behavior checklist based on tenets of clinical excellence, 2 faculty preceptors observed outpatient primary care visits with 96% (46 of 48) of the internal medicine residents in 2017. Residents self-assessed their performance after the visit using the same checklist. Next, a focused coaching feedback session, emphasizing reflection, was structured to highlight areas of discrepancy between resident self-assessment and coach observation (blind spots), and residents were asked to identify goals for practice improvement. RESULTS: Common blind spots in resident self-assessment related to collaborating with patients while using the electronic health record (48%, 21 of 44), hand washing (43%, 20 of 46), and asking thoughtful questions (40%, 18 of 45). At 1-month follow-up, 93% (43 of 46) of responding residents reported change in practice toward goals often or sometimes. All residents reported that the intervention felt comfortable, and 98% (45 of 46) noted that it helped them identify new behaviors to incorporate into clinical practice. CONCLUSIONS: Structured episodes of direct observation and coaching in the outpatient setting, with a behavior checklist, appear acceptable and useful for internal medicine residents' learning and development.

New and Emerging Illicit Psychoactive Substances.

Several novel psychoactive substances have emerged in recent years. Users are typically young men who use other substances. In the category of stimulants, cathinones ("bath salts") have predominated and can lead to agitation, psychosis, hyperthermia, and death. Synthetic cannabinoids ("spice") are more potent than marijuana and can lead to agitation, psychosis, seizures, and death. There are no rapid tests to identify these substances and general treatment includes benzodiazepines for agitation and supportive therapy. Many Synthetic opioids are potent analogues of fentanyl and carry a high risk of overdose. In addition, there are several designer benzodiazepines that have emerged.

Impact of a Mandated Change in Buprenorphine Formulation.

OBJECTIVE: This study examines the impact of an insurance-mandated change in formulation of buprenorphine/naloxone (BNX) for patients with opioid use disorder treated in a primary care clinic. METHODS: A retrospective cohort study was conducted to determine the proportion of patients who were switched back to the previous BNX formulation and rates of aberrant urine drug tests for the 3 months before and 3 months after a mandated change in BNX from the sublingual film to the rapidly dissolving tablet (BNX-RDT). Aberrant urine drug tests were defined as the presence of cocaine, nonprescribed opioids/benzodiazepines, or the absence of buprenorphine. RESULTS: In all, 186 patients were included in the analysis. At 3 months after the change, 36.0% of patients remained on BNX-RDT at equivalent dose, 9.1% were prescribed a higher dose of BNX-RDT, 52.7% were switched back to their previous formulation after a trial of BNX-RDT, and 2.2% dropped out of care. There was no significant change in the rates of aberrant urine drug tests pre and postchange (36.6% vs 33.7%; P = 0.27) or in any individual component of urine drug testing. Age, sex, and starting dose were not associated with remaining on BNX-RDT at equivalent dose, compared with increasing dose or changing formulation. CONCLUSIONS: Most patients were dissatisfied with the change in formulation and requested a return to the previous formulation. This change did not appear to impact drug use; however, the flexibility that permitted patients to switch back to their previous BNX formulation likely attenuated the policy's impact.

Going the extra mile: Lessons learned from running coaches applied to medicine.

Master clinicians and successful long-distance runners have a lot in common. Both are dedicated to continuous improvement and are flexible in their approach, allowing for adaptation to meet unplanned challenges. Given these similarities and the important role of coaches in athletics, there is an opportunity for medical educators to learn from excellent running coaching. The authors spent time with three respected running coaches at different levels (high school, college, and postcollegiate online) and identified six principles employed by these coaches that seem to be particularly relevant for promoting skill development in medicine. Three of these may be considered foundational tenets for a successful coach: know your coachee; model the qualities you seek to instill; and communicate clearly and consistently. An additional three principles represent higher order coaching skills that enable superior coaches to develop others into truly outstanding performers: be a keen observer; purposefully build strong and interconnected teams; and inspire greatness. Longitudinal, individualized coaching predicated on these six tenets may be an effective means for optimizing professional development in medicine.

Mouse TCRalphabeta+CD8alphaalpha intraepithelial lymphocytes express genes that down-regulate their antigen reactivity and suppress immune responses.

Mouse small intestine intraepithelial lymphocytes (IEL) that express alphabetaTCR and CD8alphaalpha homodimers are an enigmatic T cell subset, as their specificity and in vivo function remain to be defined. To gain insight into the nature of these cells, we performed global gene expression profiling using microarray analysis combined with real-time quantitative PCR and flow cytometry. Using these methods, TCRalphabeta(+)CD8alphaalpha IEL were compared with their TCRalphabeta(+)CD8beta(+) and TCRgammadelta(+) counterparts. Interestingly, TCRalphabeta(+)CD8alphaalpha IEL were found to preferentially express genes that would be expected to down-modulate their reactivity. They have a unique expression pattern of members of the Ly49 family of NK receptors and tend to express inhibitory receptors, along with some activating receptors. The signaling machinery of both TCRalphabeta(+)CD8alphaalpha and TCRgammadelta(+) IEL is constructed differently than other IEL and peripheral T cells, as evidenced by their low-level expression of the linker for activation of T cells and high expression of the non-T cell activation linker, which suppresses T cell activation. The TCRalphabeta(+)CD8alphaalpha IEL subset also has increased expression of genes that could be involved in immune regulation, including TGF-beta(3) and lymphocyte activation gene-3. Collectively, these data underscore the fact that, while TCRalphabeta(+)CD8alphaalpha IEL resemble TCRgammadelta(+) IEL, they are a unique population of cells with regulated Ag reactivity that could have regulatory function.