Utilizing a Faculty Development Program to Promote Safer Opioid Prescribing for Chronic Pain in Internal Medicine Resident Practices.

OBJECTIVE: To implement a skills-based faculty development program (FDP) to improve Internal Medicine faculty's clinical skills and resident teaching about safe opioid prescribing. DESIGN: An FDP for Internal Medicine attendings that included a one-hour didactic presentation followed immediately by an Objective Structured Clinical Examination (OSCE) that focused on assessing and managing opioid misuse risk, opioid treatment outcomes (benefits and harms), and aberrant opioid use behaviors. The evaluation compared pre- and three-months-post-FDP changes in faculty's safe opioid prescribing knowledge, attitudes, confidence (clinical and teaching), and self-reported resident teaching. RESULTS: The 25 Internal Medicine faculty participants had a mean of 13 years in clinical practice, including 10 years precepting residents. During the three months post-FDP, faculty treated a mean of 22 patients with chronic pain on long-term opioids and precepted a mean of seven residents caring for patients on long-term opioids. At three months post-FDP, there were significant improvements in correct responses to knowledge questions (68% to 79% P = 0.008), "high-level" confidence in safer opioid prescribing clinical practice (43.5% to 82.6% P = 0.007) and resident teaching (45.8% to 83.3%, P = 0.007), and improvements in alignment of desired attitudes toward safer opioid prescribing. There were nonsignificant increases in self-reported safe opioid prescribing resident teaching. CONCLUSIONS: A skills-based faculty development program that includes a lecture followed by an OSCE can improve Internal Medicine faculty safe opioid prescribing knowledge, attitudes, and clinical and teaching confidence. Improving resident teaching may require additional training in safe opioid prescribing teaching skills.

Promoting addiction medicine teaching through functional mentoring by co-training generalist chief residents with faculty mentors.

BACKGROUND: Generalist physicians should play a vital role in identifying and managing individuals with substance use but are inadequately trained to do so. METHODS: This 5-year (2008-2012) controlled educational study assessed whether internal medicine and family medicine chief residents' (CRs) addiction medicine teaching increased by co-training with faculty mentors at a Chief Resident Immersion Training (CRIT) program in addiction medicine. All CRIT CR attendees identified a residency program faculty mentor to support addiction medicine teaching after CRIT through functional mentoring with a focus on developing and implementing an Addiction Medicine Teaching Project ("Teaching Project"). Approximately half of the CRs attended CRIT with their mentor (co-trained) and half without their mentor (solo-trained). Addiction medicine teaching outcomes were compared between groups using 6- and 11-month questionnaires and 4 bimonthly teaching logs. Of co-trained CRs, mentor characteristics that positively influenced addiction medicine teaching outcomes were identified. RESULTS: One hundred CRs from 74 residency programs attended CRIT from 2008 to 2012; 47 co-trained with their mentors and 53 solo-trained without their mentors. At 6-month follow-up, the co-trained CRs were more likely to meet at least monthly with their mentor (22.7% vs. 9.6%, P < .01) and more likely to identify their mentor as a facilitator for Teaching Project implementation (82.2% vs. 38.5%, P < .01). At 11-month follow-up, a higher percentage of co-trained CRs had completed their Teaching Project (34.0% vs. 15.1%, P < .05). Both CR groups had similarly large increases in other addiction medicine teaching outcomes. Mentors with more experience, including years of teaching, was associated with better CR Teaching Project outcomes. CONCLUSIONS: Co-training generalist chief residents with a faculty mentor appeared to facilitate functional mentoring-driven Teaching Project implementation but did not further increase already high levels of other addiction medicine teaching. Faculty mentors with more years of teaching experience were more effective in facilitating Teaching Project implementation.

Internal medicine residency training for unhealthy alcohol and other drug use: recommendations for curriculum design.

BACKGROUND: Unhealthy substance use is the spectrum from use that risks harm, to use associated with problems, to the diagnosable conditions of substance abuse and dependence, often referred to as substance abuse disorders. Despite the prevalence and impact of unhealthy substance use, medical education in this area remains lacking, not providing physicians with the necessary expertise to effectively address one of the most common and costly health conditions. Medical educators have begun to address the need for physician training in unhealthy substance use, and formal curricula have been developed and evaluated, though broad integration into busy residency curricula remains a challenge. DISCUSSION: We review the development of unhealthy substance use related competencies, and describe a curriculum in unhealthy substance use that integrates these competencies into internal medicine resident physician training. We outline strategies to facilitate adoption of such curricula by the residency programs. This paper provides an outline for the actual implementation of the curriculum within the structure of a training program, with examples using common teaching venues. We describe and link the content to the core competencies mandated by the Accreditation Council for Graduate Medical Education, the formal accrediting body for residency training programs in the United States. Specific topics are recommended, with suggestions on how to integrate such teaching into existing internal medicine residency training program curricula. SUMMARY: Given the burden of disease and effective interventions available that can be delivered by internal medicine physicians, teaching about unhealthy substance use must be incorporated into internal medicine residency training, and can be done within existing teaching venues.

Promoting substance use education among generalist physicians: an evaluation of the Chief Resident Immersion Training (CRIT) program.

BACKGROUND: Education about substance use (SU) disorders remains inadequate in medical training. OBJECTIVE: To describe the Chief Resident Immersion Training (CRIT) program in addiction medicine and to evaluate its impact on chief resident (CR) physicians' substance use knowledge, skills, clinical practice, and teaching. DESIGN: A controlled educational study of CRIT programs (2003, 2004, and 2005) for incoming CRs in generalist disciplines. Intervention CRs were trained to diagnose, manage, and teach about SU. The control CRs sought but did not receive the intervention. PARTICIPANTS: Eighty-six CR applicants to the CRIT program. MEASUREMENTS: Baseline and 6-month questionnaires assessing substance use knowledge, skills, clinical practice, and teaching. Outcomes were compared within groups from baseline to follow-up and between groups at follow-up. RESULTS: The intervention (n = 64) and control (n = 22) CRs were similar demographically. At 6-month follow-up, the intervention CRs reported a significant increase in SU knowledge, confidence, and preparedness to diagnose, manage, and teach and an increase in SU clinical and teaching practices compared to their baseline and control CRs. CONCLUSIONS: This intensive training for chief residents (CRs) improved knowledge, confidence, and preparedness to diagnose, manage, and teach about substance use (SU), affecting both the CRs' SU clinical and teaching practices. The CRIT program was an effective model for dissemination of SU knowledge and skills to educators in a key position to share this training with a broader audience of medical trainees. This model holds potential to address other high priority medical, yet under-addressed, content areas as well.

Chief Resident Immersion Training in the Care of Older Adults: A Successful National Replication of an Interspecialty Educational Intervention.

PURPOSE: Nongeriatricians must acquire skills and knowledge in geriatric medicine to ensure coordinated care of older adults' complex conditions by interspecialty and interprofessional teams. Chief residents (CRs) are an ideal target for an educational intervention. This study examined whether the Boston Medical Center Chief Resident Immersion Training (CRIT) in the Care of Older Adults was replicable at diverse medical institutions. METHOD: Between 2008 and 2010, 12 institutions in 11 states received funding, technical support, and a common program model. Each implemented 2.5-day CRITs, consisting of a patient case, geriatrics-related lectures, CR leadership sessions, action project planning, and networking time. Site faculty conducted 21 CRITs for 295 CRs representing 28 specialties. CRs completed knowledge pre- and posttests, and self-report baseline and six-month follow-up surveys. Outcome measures were change in pre- and posttest score, and change from baseline to six months in self-reported surveys. RESULTS: Response rate for CRs was 99% (n = 293) for the pre-post tests and 78% (n = 231) for matchable baseline and follow-up surveys. Participants' knowledge increased from 6.32 to 8.39 (P < .001) averaged from 12 questions. CRs' self-reported ability to apply clinical problem-solving skills to older patients (P < .001), number of geriatrics topics taught (P < .001), frequency of geriatrician consultations (P = .017), confidence in leadership skills (P < .001), and confidence to conduct CR work (P < .001) increased from baseline to follow-up. CONCLUSIONS: CRIT is an innovative way to give nongeriatricians knowledge and skills to treat complex older patients.

Associations of medical student empathy with clinical competence.

OBJECTIVE: Empathy is a crucial skill for medical students that can be difficult to evaluate. We examined if self-reported empathy in medical students was associated with clinical competence. METHODS: This study combined cross-sectional data from four consecutive years of medical students (N=590) from the Boston University School of Medicine. We used regression analysis to evaluate if self-reported empathy (Jefferson Scale of Physician Empathy (JSPE)) predicted scores in clinical clerkships, United States Medical Licensing Examinations, and OBJECTIVE: Structured Clinical Examinations (OSCEs). We separately analyzed overall and OSCE communication scores based on interpersonal skills reported by standardized patients. We controlled for age, gender, debt, and specialty affinity. RESULTS: JSPE scores of medical students were positively associated with OSCE communication scores, and remained significant when controlling for demographics. We found that JSPE score was also predictive of overall OSCE scores, but this relationship was confounded by gender and age. JSPE scores were associated with performance in the Pediatrics clerkship, but not other clerkships or standardized tests. CONCLUSION: JSPE scores were positively associated with OSCE communication scores in medical students. PRACTICE IMPLICATIONS: This study supports that self-reported empathy may predict OSCE performance, but further research is needed to examine differences by gender and age.

Improving Residents' Safe Opioid Prescribing for Chronic Pain Using an Objective Structured Clinical Examination.

BACKGROUND: Internal medicine residents care for a sizable number of patients with chronic pain. Programs need educational strategies to promote safe opioid prescribing. OBJECTIVE: To describe a safe opioid prescribing education program utilizing an objective structured clinical examination (OSCE) and report the resulting impact on residents' knowledge, confidence, and self-reported practices. METHODS: Using a quasi-experimental design, 39 internal medicine residents from an urban academic medical center were assigned to 1 of 4 groups: 1-hour lecture only, lecture followed by immediate OSCE, lecture followed by 4-month delayed OSCE, and control. Safe opioid prescribing knowledge, confidence, and self-reported practices were assessed at baseline and at 8 months. RESULTS: At 8 months, knowledge, confidence, and self-reported practices improved in the control and in all 3 intervention groups. The immediate OSCE group had the greatest improvements in combined confidence scores within group (0.74, P = .01) compared to controls (0.52, P = .05), using a 5-point scale. This group also had the greatest improvement in self-reported practice changes (1.04, P = .04), while other groups showed nonsignificant improvements-delayed OSCE (0.43, P = .44), lecture only (0.66, P = .24), and control (0.43, P = .19). CONCLUSIONS: Safe opioid prescribing education that includes a lecture immediately followed by an OSCE had an impact on residents' confidence and self-reported practices greater than those for delayed OSCE or lecture only groups. There was no difference in knowledge improvement among the groups. Lecture followed by an OSCE was highly regarded by residents, but required additional resources.

Chief resident immersion training in the care of older adults: an innovative interspecialty education and leadership intervention.

Chief residents (CRs) play a crucial role in training residents and students but may have limited geriatrics training or formal preparation for their CR role. A 2-day off-site chief resident immersion training (CRIT) addressed these challenges. Objectives were to foster collaboration between disciplines in the management of complex older patients, increase knowledge of geriatrics principles to incorporate into teaching, enhance leadership skills, and help CRs develop an achievable project for implementation in their CR year. Three cohorts totaling 47 trainees and 18 faculty mentors from 13 medical and surgical disciplines participated over 3 successive years. The curriculum, developed and taught by a multidisciplinary team, featured an interactive surgical case, mini-lectures on geriatrics topics, seminars to enhance teaching and leadership skills, and one-on-one mentoring to develop a project in geriatric care or education. Evaluation included pre- and postprogram tests and self-report surveys and two follow-up surveys or interviews. In 2006 and 2007, scores on a 12-item objective knowledge test increased significantly (P<.001) from before to immediately after CRIT. Self-report knowledge and confidence in teaching geriatrics also increased significantly (P<.05) in all formally covered topics. Mean enhancement of CR skills was 4.3 (1=not at all, 5=very much). Eleven months after CRIT, all but five CRs had implemented at least part of their action projects. CRs reported improved care of older patients, better leadership skills, more and better geriatrics teaching, and more collaboration between disciplines. A 2-day interactive program for CRs can increase institutional capacity regarding geriatrics teaching and care of elderly patients across medical specialties.