Simulation-Based Education in Acute and Chronic Pain Training.

PURPOSE OF REVIEW: The use of simulation-based education (SBE) in medical training has expanded greatly and has grown to include high fidelity and task simulation along with hybrid models using patient actors to enhance education and training of critical events as well as technical skills. RECENT FINDINGS: In the field of anesthesiology, SBE has been particularly useful for crisis resource management and rare critical scenarios and new research into the use of SBE using task simulation for procedural skill development has been done highlighting the benefits to subspecialty procedural training. Medical simulation has become a common practice in medical training and research. SBE has demonstrated positive outcomes in improving technical skills, knowledge, comfort, and clinical performance. The widespread implementation of SBE in regional anesthesia and chronic pain training varies, with cost and availability being factors. Nonetheless, SBE has shown great potential in enhancing education and preparing physicians in subspecialties of anesthesia.

Simplified Universal Grading of Lumbar Spine MRI Degenerative Findings: Inter-Reader Agreement of Non-Radiologist Spine Experts.

OBJECTIVE: 1) To describe a simplified multidisciplinary grading system for the most clinically relevant lumbar spine degenerative changes. 2) To measure the inter-reader variability among non-radiologist spine experts in their use of the classification system for interpretation of a consecutive series of lumbar spine magnetic resonance imaging (MRI) examinations. METHODS: ATS multidisciplinary and collaborative standardized grading of spinal stenosis, foraminal stenosis, lateral recess stenosis, and facet arthropathy was developed. Our institution's picture archiving and communication system was searched for 50 consecutive patients who underwent non-contrast MRI of the lumbar spine for chronic back pain, radiculopathy, or symptoms of spinal stenosis. Three fellowship-trained spine subspecialists from neurosurgery, orthopedic surgery, and physiatry interpreted the 50 exams using the classification at the L4-L5 and L5-S1 levels. Inter-reader agreement was assessed with Cohen's kappa coefficient. RESULTS: For spinal stenosis, the readers demonstrated substantial agreement (κ = 0.702). For foraminal stenosis and facet arthropathy, the three readers demonstrated moderate agreement (κ = 0.544, and 0.557, respectively). For lateral recess stenosis, there was fair agreement (κ = 0.323). CONCLUSIONS: A simplified universal grading system of lumbar spine MRI degenerative findings is newly described. Use of this multidisciplinary grading system in the assessment of clinically relevant degenerative changes revealed moderate to substantial agreement among non-radiologist spine physicians. This standardized grading system could serve as a foundation for interdisciplinary communication.

Individual, organizational, and policy strategies to enhance the retention and a sense of belonging for health care professionals in rehabilitation medicine.

The retention of physicians and other health care professionals in rehabilitation medicine is a critical issue that affects patients' access to care and the quality of the care they receive. In the United States and globally, there are known shortages of clinicians including, but not limited to, physicians, nurses, physical therapists, occupational therapists, and speech-language pathologists. These shortages are predicted to worsen in the future. It is known that attrition occurs in a variety of ways such as a clinician reducing work hours or effort, taking a position at another organization, leaving the field of medicine altogether, stress-related illness, and suicide. Retention efforts should focus on stay factors by creating a positive culture that supports a sense of belonging as well as addressing a myriad of push and pull factors that lead to attrition. In this commentary, we provide a roadmap that includes examples of stay strategies for individuals and organizations to adopt that are aimed at enhancing the retention of rehabilitation medicine professionals.

The Pain Intervention & Digital Research Program: an operational report on combining digital research with outpatient chronic disease management.

Chronic pain affects up to 28% of U.S. adults, costing ∼$560 billion each year. Chronic pain is an instantiation of the perennial complexity of how to best assess and treat chronic diseases over time, especially in populations where age, medical comorbidities, and socioeconomic barriers may limit access to care. Chronic disease management poses a particular challenge for the healthcare system's transition from fee-for-service to value and risk-based reimbursement models. Remote, passive real-time data from smartphones could enable more timely interventions and simultaneously manage risk and promote better patient outcomes through predicting and preventing costly adverse outcomes; however, there is limited evidence whether remote monitoring is feasible, especially in the case of older patients with chronic pain. Here, we introduce the Pain Intervention and Digital Research (Pain-IDR) Program as a pilot initiative launched in 2022 that combines outpatient clinical care and digital health research. The Pain-IDR seeks to test whether functional status can be assessed passively, through a smartphone application, in older patients with chronic pain. We discuss two perspectives-a narrative approach that describes the clinical settings and rationale behind changes to the operational design, and a quantitative approach that measures patient recruitment, patient experience, and HERMES data characteristics. Since launch, we have had 77 participants with a mean age of 55.52, of which n = 38 have fully completed the 6 months of data collection necessitated to be considered in the study, with an active data collection rate of 51% and passive data rate of 78%. We further present preliminary operational strategies that we have adopted as we have learned to adapt the Pain-IDR to a productive clinical service. Overall, the Pain-IDR has successfully engaged older patients with chronic pain and presents useful insights for others seeking to implement digital phenotyping in other chronic disease settings.

The Role of Surgical Prehabilitation During the COVID-19 Pandemic and Beyond.

The challenging circumstances of the COVID-19 pandemic caused a regression in baseline health of disadvantaged populations, including individuals with frail syndrome, older age, disability, and racial-ethnic minority status. These patients often have more comorbidities and are associated with increased risk of poor postoperative complications, hospital readmissions, longer length of stay, nonhome discharges, poor patient satisfaction, and mortality. There is critical need to advance frailty assessments to improve preoperative health in older populations. Establishing a gold standard for measuring frailty will improve identification of vulnerable, older patients, and subsequently direct designs for population-specific, multimodal prehabilitation to reduce postoperative morbidity and mortality.

Rehabilitation clinical trials in global registries: reporting of participant inclusion by sex, age, race and ethnicity.

PURPOSE: Registries of clinical trials exist in part to standardize data for the scientific community. Studies in the United States demonstrated gaps in reporting on ClinicalTrials.gov. The purpose of this cross-sectional study was to evaluate clinical trial participation among global registries. METHODS: This study identified registries with results reported and assessed available results for physical and rehabilitation medicine (PRM) diagnosis, intervention, primary outcome, and the International Classification of Functioning, Disability and Health (ICF) categories. Participant characteristics including sex, age, and race/ethnicity were assessed. RESULTS: A total of 93 rehabilitation trials from eight registries met inclusion criteria. Most trials included persons with musculoskeletal disorders (50.5%), technology such as robotics (25.8%) and outcomes in ICF category of body functions and structures (54.7%). Sex was reported in 61.3% of trials and varied among registries (0 to 100%). Participation of women in trials showed variability from 0 to 75%. Reporting of age of the participants was not uniform and six registries did not include age in all trials. Information about race/ethnicity was absent in most trials and registries. CONCLUSIONS: Based on trials registered with accessible results, these findings may reveal either a gap in reporting results or a lack of trials investigating important PRM diagnoses, interventions, and outcomes.Implications for RehabilitationThis study contributes to the growing body of evidence that there are gaps in standardization of rehabilitation results reported on clinical trials registries.The uniform reporting of results is an important component of advancing rehabilitation science and may be a factor in high-quality study design and improved transparency.

Fabrication Methods and Chronic In Vivo Validation of Mechanically Adaptive Microfluidic Intracortical Devices.

Intracortical neural probes are both a powerful tool in basic neuroscience studies of brain function and a critical component of brain computer interfaces (BCIs) designed to restore function to paralyzed patients. Intracortical neural probes can be used both to detect neural activity at single unit resolution and to stimulate small populations of neurons with high resolution. Unfortunately, intracortical neural probes tend to fail at chronic timepoints in large part due to the neuroinflammatory response that follows implantation and persistent dwelling in the cortex. Many promising approaches are under development to circumvent the inflammatory response, including the development of less inflammatory materials/device designs and the delivery of antioxidant or anti-inflammatory therapies. Here, we report on our recent efforts to integrate the neuroprotective effects of both a dynamically softening polymer substrate designed to minimize tissue strain and localized drug delivery at the intracortical neural probe/tissue interface through the incorporation of microfluidic channels within the probe. The fabrication process and device design were both optimized with respect to the resulting device mechanical properties, stability, and microfluidic functionality. The optimized devices were successfully able to deliver an antioxidant solution throughout a six-week in vivo rat study. Histological data indicated that a multi-outlet design was most effective at reducing markers of inflammation. The ability to reduce inflammation through a combined approach of drug delivery and soft materials as a platform technology allows future studies to explore additional therapeutics to further enhance intracortical neural probes performance and longevity for clinical applications.

Gender Representation Among United States Medical Board Leadership.

Objective: To assess the gender composition of the American Board of Medical Specialties' (ABMS) member boards and evaluate the equitable inclusion of women and a subset of women physicians. Methods: The gender of individuals on 24 boards as of March 1, 2022, was assessed. Two benchmarks-parity (50:50 representation) and equity (compared to the proportion of practicing physicians in each medical specialty)-were utilized to determine if women are equitably represented on medical boards. Results: Four hundred forty individuals hold 449 total positions on the boards examined. Of board the members, 60.7% (267/440) are men, and 92.3% (406/440) are physicians. Physician board members comprised more men (64.0%, 260/406; p < 0.001), whereas more women comprise the 34 nonphysician board members (79.4%, 27/34; p < 0.001). Using specialty representation (equity) as the benchmark, of 22 specialties for which physician gender/sex data are available, women physicians are underrepresented on 36.4% (8/22) of boards. When parity (50%) is the comparator, 72.0% (18/25) of boards comprised less than 50% women. Compared to a 2016 analysis, the proportion of women overall (including non-physicians) increased on 68.0% (17/25), decreased on 24.0% (6/25), and remained unchanged on 8.0% (2/25) of boards in 2022. Conclusions: This study reveals mixed results in the equitable inclusion of women on ABMS boards. Our findings suggest that progress should not be assumed and that it may be subject to setbacks when it occurs. There is a need to continue to monitor the equitable inclusion of women on ABMS boards.

A novel interventional pain simulation-based education curriculum: Implementation to enhance procedural training.

Several studies have demonstrated the benefits of simulation-based education (SBE) across all trainee levels in various medical fields. These benefits include allowing trainees greater autonomy and the opportunity to learn from mistakes in bioethical and procedural scenarios without compromising patient safety. While much progress has been made, there is little research on the implementation of SBE in pain medicine. This study investigated the effects of interventional pain SBE on 37 pain medicine fellows at the Brigham and Women's Hospital Pain Medicine Fellowship. The study found that fellows' performance, knowledge, and comfort were enhanced by the implementation of this curriculum.

Clinician Experiences in Treatment Decision-Making for Patients with Spinal Metastases: A Qualitative Study.

BACKGROUND: Effective management of metastatic disease requires multidisciplinary input and entails high risk of disease-related and treatment-related morbidity and mortality. The factors that influence clinician decision-making around spinal metastases are not well understood. We conducted a qualitative study that included a multidisciplinary cohort of physicians to evaluate the decision-making process for treatment of spinal metastases from the clinician's perspective. METHODS: We recruited operative and nonoperative clinicians, including orthopaedic spine surgeons, neurosurgeons, radiation oncologists, and physiatrists, from across North America to participate in either a focus group or a semistructured interview. All interviews were audiorecorded and transcribed verbatim. We then performed a thematic analysis using all of the available transcript data. Investigators sequentially coded transcripts and identified recurring themes that encompass overarching patterns in the data and directly bear on the guiding study question. This was followed by the development of a thematic map that visually portrays the themes, the subthemes, and their interrelatedness, as well as their influence on treatment decision-making. RESULTS: The thematic analysis revealed that numerous factors influence provider-based decision-making for patients with spinal metastases, including clinical elements of the disease process, treatment guidelines, patient preferences, and the dynamics of the multidisciplinary care team. The most prominent feature that resonated across all of the interviews was the importance of multidisciplinary care and the necessity of cohesion among a team of diverse health-care providers. Respondents emphasized aspects of care-team dynamics, including effective communication and intimate knowledge of team-member preferences, as necessary for the development of appropriate treatment strategies. Participants maintained that the primary role in decision-making should remain with the patient. CONCLUSIONS: Numerous factors influence provider-based decision-making for patients with spinal metastases, including multidisciplinary team dynamics, business pressure, and clinician experience. Participants maintained a focus on shared decision-making with patients, which contrasts with patient preferences to defer decisions to the physician, as described in prior work. CLINICAL RELEVANCE: The results of this thematic analysis document the numerous factors that influence provider-based decision-making for patients with spinal metastases. Our results indicate that provider decisions regarding treatment are influenced by a combination of clinical characteristics, perceptions of patient quality of life, and the patient's preferences for care.