Curricular Reform in Serious Illness Communication and Palliative Care: Using Medical Students' Voices to Guide Change.

PURPOSE: To gather and leverage the voices of students to drive creation of required, integrated palliative care curricula within undergraduate medical education in Massachusetts, which is lacking in a majority of U.S. medical schools. METHOD: The study was conducted by the Massachusetts Medical Schools' Collaborative, a working group committed to ensuring all medical students in Massachusetts receive foundational training in serious illness communication (SIC) and palliative care. Eight focus groups (2 per participating medical school) were conducted during January-May 2021 and included a total of 50 students from Boston University Chobanian & Avedisian School of Medicine, Harvard Medical School, Tufts University School of Medicine, and the UMass Chan Medical School. Data collected from focus groups were discussed and coded. Themes were identified using the immersion/crystallization qualitative data analysis approach. RESULTS: Six key themes emerged. Students viewed SIC as essential to high-quality medical practice regardless of specialty, and believed training in SIC skills and palliative care should be required in medical school curricula. Students preferred to learn and practice these skills using frameworks, particularly in real-world situations. Students recognized the expertise of palliative care specialists and described them as a scarce, often misunderstood resource in health care. Students reported it was mostly "luck" if they were included in family meetings and observed good role models. Finally, students desired practice in debriefing after difficult and emotional situations. CONCLUSIONS: This study confirms long-standing themes on students' experiences with SIC and palliative care topics, including feeling inadequately prepared to care for seriously ill patients as future physicians. Our study collected students' perspectives as actionable data to develop recommendations for curricular change. Collaborative faculty also created recommendations based on the focus group data for immediate and ongoing SIC and palliative care curricular change in Massachusetts, which can apply to medical schools nationwide.

Fostering Success and Promoting Professional Development of Clinician Educator Mentees: A Workshop for Mentors.

Introduction: The goal of academic mentoring relationships is to enable the mentee to identify/achieve professional advancement. Although mentors of clinician educators (CEs) must understand the criteria for successful career advancement, few have received formal CE mentor training. Methods: The National Research Mentoring Network convened an expert panel to develop a 90-minute module for training CE mentors. This module included individual development plans, case studies involving challenges for CE faculty, and examples of the broadened scope of scholarly activity. The workshop was delivered to 26 participants across four institutions and evaluated by a retrospective pre/post survey. Results: Using a 7-point scale (1 = very low, 4 = average, 7 = very high), participants rated the overall quality of their CE mentoring as slightly below average preworkshop (M = 3.9) and as above average postworkshop (M = 5.2, p < .001). Areas of greatest self-perceived change in skills on a 7-point scale (1 = not at all skilled, 4 = moderately skilled, 7 = extremely skilled ) included setting clear expectations of the mentoring relationship (pre M = 3.6, post M = 5.1, p < .001), aligning mentor expectations with those of mentees (pre M = 3.6, post M = 5.0, p < .001), and helping mentees set career goals (pre M = 3.9, post M = 5.4, p < .001). Discussion: This module trains CE mentors using an interactive and collective problem-solving approach. Workshop participants better defined demonstrable markers for CE progression with potential to impact tailored guidance for mentees.

Posthospital home visit as teaching tool for internal medicine residents.

Internal medicine residency programs consider effectively discharging patients from the hospital an important training milestone. However, it is rare for residents to have the opportunity to follow discharged patients into the community and see discharge plans in action. This curriculum provided residents with the opportunity to evaluate patients in their homes after they were discharged from the hospital to assess the alignment of the discharge plan with patients' real-life circumstances. Thirty-nine internal medicine residents participated in a structured exercise during a posthospital discharge home visit to older patients they cared for during the hospital admission. After completing the exercise, residents were asked what they learned from the experience. We found that by visiting patients' homes, residents were able to better assess patient needs, which highlighted the necessity for more individualized discharge plans with regard to in-home functioning, communication with caregivers, and medication reconciliation. Further, the posthospital visit exercise enhanced residents' awareness of challenges in developing and implementing discharge care plans for complex older patients.

Faculty Communication Knowledge, Attitudes, and Skills Around Chronic Non-Malignant Pain Improve with Online Training.

OBJECTIVE: Many physicians struggle to communicate with patients with chronic, non-malignant pain (CNMP). Through the use of a Web module, the authors aimed to improve faculty participants' communication skills knowledge and confidence, use of skills in clinical practice, and actual communication skills. SUBJECTS: The module was implemented for faculty development among clinician-educators with university faculty appointments, outpatient clinical practices, and teaching roles. METHODS: Participants completed the Collaborative Opioid Prescribing Education Risk Evaluation and Mitigation Strategy (COPE-REMS®) module, a free Web module designed to improve provider communication around opioid prescribing. Main study outcomes were improvements in CNMP communication knowledge, attitudes, and skills. Skills were assessed by comparing a subset of participants' Observed Structured Clinical Exam (OSCE) performance before and after the curriculum. RESULTS: Sixty-two percent of eligible participants completed the curriculum in 2013. Knowledge-based test scores improved with curriculum completion (75% vs. 90%; P < 0.001). Using a 5-point Likert-type scale, participants reported improved comfort in managing patients with CNMP both immediately post-curriculum and at 6 months (3.6 pre vs. 4.0 post vs. 4.1 at 6 months; P = 0.02), as well as improvements in prescribing opioids (3.3 vs. 3.8 vs. 3.9, P = 0.01) and conducting conversations about discontinuing opioids (2.8 vs. 3.5 vs. 3.9, P < 0.001). Additionally, CNMP-specific communication skills on the OSCE improved after the curriculum (mean 67% vs. 79%, P = 0.03). CONCLUSIONS: Experienced clinician-educators improved their communication knowledge, attitudes, and skills in managing patients with CNMP after implementation of this curriculum. The improvements in attitudes were sustained at six months. A Web-based curriculum such as COPE-REMS® may be useful for other programs seeking improvement in faculty communication with patients who have CNMP.

Optimizing health for complex adults in primary care: current challenges and a way forward.

As the population ages, the quantity and complexity of comorbidities only increases in the primary care setting. Health systems strive to improve quality of care and enhance cost savings, but current administrative and payment systems do not easily support the implementation of existing evidence and best practices for multimorbid adults in most primary care offices. This perspectives piece sets forth a research agenda in the area of implementation science at the intersection of geriatrics and general internal medicine. We challenge academic medical centers, medical societies, journals, and funders to actively value and support investigation in this area as much as traditional research pathways.

Complexity in graduate medical education: a collaborative education agenda for internal medicine and geriatric medicine.

Internal medicine residents today face significant challenges in caring for an increasingly complex patient population within ever-changing education and health care environments. As a result, medical educators, health care system leaders, payers, and patients are demanding change and accountability in graduate medical education (GME). A 2012 Society of General Internal Medicine (SGIM) retreat identified medical education as an area for collaboration between internal medicine and geriatric medicine. The authors first determined a short-term research agenda for resident education by mapping selected internal medicine reporting milestones to geriatrics competencies, and listing available sample learner assessment tools. Next, the authors proposed a strategy for long-term collaboration in three priority areas in clinical medicine that are challenging for residents today: (1) team-based care, (2) transitions and readmissions, and (3) multi-morbidity. The short-term agenda focuses on learner assessment, while the long-term agenda allows for program evaluation and improvement. This model of collaboration in medical education combines the resources and expertise of internal medicine and geriatric medicine educators with the goal of increasing innovation and improving outcomes in GME targeting the needs of our residents and their patients.

Using elements from an acute abdominal pain Objective Structured Clinical Examination (OSCE) leads to more standardized grading in the surgical clerkship for third-year medical students.

BACKGROUND: There is poor reliability in the Likert-based assessments of patient interaction and general knowledge base for medical students in the surgical clerkship. The Objective Structured Clinical Examination (OSCE) can be used to assess these competencies. OBJECTIVE: We hypothesize that using OSCE performance to replace the current Likert-based patient interaction and general knowledge base assessments will not affect the pass/fail rate for third-year medical students in the surgical clerkship. METHODS: In this retrospective study, third-year medical student clerkship data from a three-station acute abdominal pain OSCE were collected from the 2009-2010 academic year. New patient interaction and general knowledge base assessments were derived from the performance data and substituted for original assessments to generate new clerkship scores and ordinal grades. Two-sided nonparametric statistics were used for comparative analyses, using an α = 0.05. RESULTS: Seventy third-year medical students (50.0% female) were evaluated. A sign test showed a difference in the original (4.45/5) and the new (4.20/5) median patient interaction scores (p < 0.01). A sign test did not show a difference in the original (4.00/5) and the new (4.11/5) median general knowledge base scores (p = 0.28). Nine clerkship grades changed between these different grading schemes (p = 0.045), with an overall agreement of 87.1% and a kappa statistic of 0.81. There were no differences in the pass/fail rate (p > 0.99). CONCLUSIONS: We conclude that there are no differences in pass/fail rate, but there is a more standardized distribution of patient interaction assessments and utilization of the full spectrum of possible passing grades. We recommend that the current patient interaction assessment for third-year medical students in the surgical clerkship be replaced with that found through trained standardized patients in this three-station acute abdominal pain OSCE.

Systematic outpatient screening for the elderly: care of the vulnerable elderly practice improvement module to assess resident care of older adults.

OBJECTIVES: To determine the feasibility of using the American Board of Internal Medicine Care of the Vulnerable Elderly Practice Improvement Module (CoVE PIM) in an internal medicine residency program and to assess aggregate resident documentation of geriatric screening in continuity clinics. DESIGN: Needs assessment chart review for single-site pre-/postintervention study. SETTING: Internal medicine resident primary care continuity clinics. PARTICIPANTS: Thirty-seven postgraduate year (PGY)-1 and PGY-2 internal medicine residents. MEASUREMENTS: Completion rate and time of CoVE PIM chart review, CoVE PIM user difficulty, and aggregate percentage of charts documenting geriatric screening measures. RESULTS: Sixty-five percent of residents completed the CoVE PIM in an average of 47 minutes (range 30-90 minutes); 72% of resident surveys rated the CoVE PIM as easy to use. Residents demonstrated very good documentation of chronic medical conditions, smoking status, height, weight, and blood pressure and poor documentation of falls and fall risk, hearing assessment, postural hypotension, balance, rigidity, bradykinesia, home safety assessment, seat belt counseling, code status, and surrogate decision-maker. CONCLUSION: The CoVE PIM can be used to assess aggregate resident performance of geriatric screening measures. In resident clinics, general adult screening performed by nurses is well documented, whereas geriatric-specific screening performed by physicians is poorly documented.

A qualitative study of physicians' experiences with online learning in a masters degree program: benefits, challenges, and proposed solutions.

BACKGROUND: In response to challenges to faculty development (e.g. time away from clinical, teaching, and other responsibilities; lack of mentors; and limited resources) online learning has become an important venue to provide education for physicians in curriculum development, instruction, assessment, evaluation, educational leadership, and education scholarship. Online learning however has its own unique challenges. Little is known about clinician-educators' experiences while participating in online programs and few studies have focused on their approaches to facilitate online learning. AIM: To explore the experiences of physicians pursuing a degree in higher education with online learning, including motivations for choosing this format, barriers encountered, and ideas for facilitating learning in the online environment. METHOD: All students (n = 71) enrolled in online courses in the University of Illinois at Chicago Masters of Health Profession Education Program were surveyed in the spring of 2006. Responses were analysed using a qualitative approach. RESULTS: Of the 48 students who completed the survey (response rate 68%) 45 (94%) were physicians. The online format is convenient, flexible, and may be beneficial for learning. Students' responses raise issues inherent to online learning that must be addressed to optimize student-centered learning. These issues relate to: clarity of communication; difficulties in negotiating team work and in building relationships; technical demands; learning style preferences, and time commitment. Students provided recommendations for strategies to address these issues such as how to communicate clearly, facilitate teamwork, and optimize time management. Member checking supported the analysis. CONCLUSIONS: Online education programs meet the needs of physicians but have associated challenges. Further research is needed to explore the potential value of student suggested ways to optimize the online learning experience.