Development and implementation of a COVID-19 Vaccine and Pandemic Planning course: An interprofessional education approach.

We developed an online interprofessional COVID-19 Vaccine and Pandemic Planning course at the height of the pandemic to prepare health science students for future vaccine delivery. Faculty from nursing, pharmacy, medical, and dentistry developed a six-week online co-curricular interprofessional education activity open to all health science students across seven schools on three campuses within the same University system. Total enrollment included 303, with 228 completing the course from 16 programs. The majority of students were from the Doctorate in Dental Surgery (DDS) program (26.2%) and the Midwestern urban campus (90.3%). Successful rapid course development and implementation was attributed to several factors. The broad range of students across health science programs and differing years in respective programs provides insight to plan future co-curricular activities. The rapid development of a system-wide health science IPE course has implications for continuously changing professional health education needs.

Communicating value to patients-a high-value care communication skills curriculum.

INTRODUCTION: With rising health care costs in the United States, trainees will be increasingly challenged in discussing testing stewardship with patients. OBJECTIVE: We piloted a high-value care (HVC) communication skills curriculum utilizing the Four Habits Model for communication. We hoped residents would 1) learn to apply the Four Habits communication model to HVC discussions with standardized patients (SP) and 2) improve value-based communication skills through training in a high-intensity curriculum with feedback from trained faculty facilitators and peers. METHODS: Thirty interns at the University of Minnesota were randomized to a standard HVC communication SP encounter (n = 15) or a high-intensity HVC communication skills curriculum (n = 15). The high-intensity curriculum included video and audio-recorded SP encounters followed by facilitated small group discussions/feedback. Experiences were reported in a post-intervention survey; communication skills were assessed with the CARE empathy scale. RESULTS: 70% (21/30) of interns (57% high intensity, 43% standard) responded to the survey. In total, 88% of high intensity v. 44% of standard interns agreed/strongly agreed that the curriculum was valuable for their communication skills. High-intensity interns were more likely to report that feedback was valuable with subsequent incorporation of feedback into future patient encounters. High-intensity participants also reported higher levels of interest in future HVC curricula (55% vs 22%). CONCLUSION: There was no difference in overall performance on the CARE empathy scale. Our HVC high-intensity skills curriculum was well received by interns and provided opportunities to practice structured conversations and debrief around testing stewardship.

Training primary care clinicians in motivational interviewing: a comparison of two models.

OBJECTIVES: To evaluate implementing two training models for motivational interviewing (MI) to address tobacco use with primary care clinicians. METHODS: Clinicians were randomized to moderate or high intensity. Both training modalities included a single ½ day workshop facilitated by MI expert trainers. The high intensity (HI) training provided six booster sessions including telephone interactions with simulated patients and peer coaching by MI champions over 3 months. To assess performance of clinicians to deliver MI, an objective structured clinical evaluation (OSCE) was conducted before and 12 weeks after the workshop training. RESULTS: Thirty-four clinicians were enrolled; 18 were randomly assigned to HI. Compared to the moderate intensity group, the HI group scored significantly higher during the OSCE for three of six global Motivational Interviewing Treatment Integrity scale scores. There was also significant improvement for three of the four measures of MI counseling knowledge, skills and confidence. CONCLUSIONS: Using champions and telephone interactions with simulated patients as enhancement strategies for MI training programs is feasible in the primary care setting and results in greater gains in MI proficiency. PRACTICE IMPLICATIONS: Results confirm and expand evidence for use of booster sessions to improve the proficiency of MI training programs for primary care clinicians.

An interactive handoff workshop to improve intern readiness in patient care transitions.

INTRODUCTION: Patient handoffs are common during residency and are often performed with little or no training. We devised a simple intervention to improve the readiness of interns to perform handoffs. METHODS: We administered a 90-minute interactive workshop during intern orientation in 2009 and 2010. It consisted of a discussion, a case presentation, and a trigger video, followed by debriefing and a role-play exercise. The workshop required minimal technology and materials. Interns were surveyed on their readiness to perform handoffs before and after the workshop as well as 3 to 6 months after the workshop. RESULTS: Eighty-nine interns participated in the workshop during a 2-year period. Seventy-four survey responses were collected. Self-reported readiness to perform a handoff increased by 26%. A total of 91% and 81% of respondents in 2010 and 2009, respectively, reported using aspects of the workshop up to 6 months later. CONCLUSION: A brief workshop can improve interns' readiness to perform handoffs.

Toward an ecological perspective of resident teaching clinic.

Teaching clinic managers struggle to convert performance data into meaningful behavioral change in their trainees, and quality improvement measures in medicine have had modest results. This may be due to several factors including clinical performance being based more on team function than individual action, models of best practice that are over-simplified for real patients with multiple chronic diseases, and local features that influence behavior but are not aligned with core values. Many are looking for a new conceptual structure to guide them. In this paper we briefly review several theories of action from the social and complexity sciences, and synthesize these into a coherent 'ecological perspective'. This perspective focuses on stabilizing features and narrative, which select for behaviors in clinic much like organisms are selected for in an ecosystem. We have found this perspective to be a useful guide for design, measurement, and joint learning in the teaching clinic.

Patient race and physicians' decisions to prescribe opioids for chronic low back pain.

Nonwhite patients are less likely than white patients to have their pain adequately treated. This study examined the influence of patient race and patient verbal and nonverbal behavior on primary care physicians' treatment decisions for chronic low back pain in men. We randomly assigned physicians to receive a paper-based, clinical vignette of a chronic pain patient that differed in terms of patient race (white vs. black), verbal behavior ("challenging" vs. "non-challenging"), and nonverbal behavior (confident vs. dejected vs. angry). We employed a between-subjects factorial design and surveyed primary care physicians (N=382), randomly selected from the American Medical Association Physician Masterfile. The primary dependent measure was the physician's decision as to whether (s)he would switch the patient to a higher dose or stronger type of opioid. Logistic regression was used to determine the effects of patient characteristics on physicians' prescribing decisions. There was a significant interaction between patient verbal behavior and patient race on physicians' decisions to prescribe opioids. Among black patients, physicians were significantly more likely to state that they would switch to a higher dose or stronger opioid for patients exhibiting "challenging" behaviors (e.g., demanding a specific narcotic, exhibiting anger) compared to those exhibiting "non-challenging" behaviors (55.1%). For white patients there was an opposite pattern of results in which physicians were slightly more likely to escalate treatment for patients exhibiting "non-challenging" (64.3%) vs. "challenging" (54.5%) verbal behaviors. Results point to the need for better understanding of the way a complex interplay of non-clinical characteristics affects physician behavior in order to improve quality of pain management and other clinical decision-making.

Changing residents' beliefs and concerns about treating chronic noncancer pain with opioids: evaluation of a pilot workshop.

OBJECTIVE: To determine if a pilot phase workshop influenced residents' beliefs and concerns about using opioids for chronic noncancer pain. DESIGN: Pre- and post-survey questionnaire. SETTING: University residency program. PARTICIPANTS: Seventy-two Medicine and Medicine-Pediatrics residents. INTERVENTIONS: Participation in a 4-hour workshop based on adult learning theory. OUTCOME MEASURES: Residents' pre- and post-workshop concerns, feelings, and beliefs about the efficacy and safety of opioids for chronic noncancer pain (low back pain), and barriers to prescribing them (paired t-tests). RESULTS: On a scale of 1 = least to 10 = most, residents' concerns about addiction risk from opioids in patients with chronic noncancer pain dropped significantly (P < 0.001) after the workshop (Pre 6.02 to Post 3.07). Similar changes were observed regarding concerns about abuse (5.61 to 3.92), side effects (4.88 to 2.88), limiting use of other treatments (5.41 to 3.60), sanctioning (State Board; 4.27 to 3.71; Legal 4.22 to 3.43), and drawing criticism from attending staff (4.50 to 2.77), with P < 0.001 for each. Their beliefs about efficacy and safety of opioids for chronic noncancer pain increased (Pre 4.96 to Post 7.40), and they were more comfortable prescribing them (4.30 to 6.82), with P < 0.001 for both. After the workshop, nine of 13 barriers to prescribing opioids for chronic noncancer pain were significantly (P < 0.05) lower. CONCLUSION: Residents' beliefs and concerns about using opioids for chronic noncancer pain changed after participating in a 4-hour interactive workshop.

Medical residents' beliefs and concerns about using opioids to treat chronic cancer and noncancer pain: a pilot study.

This study assessed and compared residents' beliefs and concerns about using opioids for treating pain in patients with cancer and noncancer low back pain (NLBP). Participants included 72 Internal Medicine and Medicine-Pediatrics residents who completed a survey questionnaire. Based on a scale of 0 = "No concern" to 10 = "Very concerned," residents expressed greater concern that treating NLBP with opioids, compared with cancer-related pain, causes addiction (6.01 vs 1.15), abuse (5.57 vs 1.39), and side effects (4.76 vs 2.87); limits other treatments (5.36 vs 1.30); draws criticism from faculty (4.33 vs 0.88); or risks sanctioning (state board 4.12 vs 1.12, legal 4.06 vs 1.17); p < 0.001 for each (paired t-tests). They had more comfort (8.94 vs 4.31) and more empathy (9.09 vs 6.79) using opioids to treat for cancer pain than NLBP and would give whatever doses necessary for pain control (8.41 vs 3.66); p < 0.001 for each. Our findings show that residents are far more concerned about using opioids to treat NLBP than cancer-related pain.

Testing the exportability of a tool for detecting operational problems in VA teaching clinics.

BACKGROUND: Recurrent operational problems in teaching clinics may be caused by the different medical preferences of patients, residents, faculty, and administrators. These preference differences can be identified by cultural consensus analysis (CCA), a standard anthropologic tool. OBJECTIVE: This study tests the exportability of a unique CCA tool to identify site-specific operational problems at 5 different VA teaching clinics. DESIGN: We used the CCA tool at 5 teaching clinics to identify group preference differences between the above groups. We averaged the CCA results for all 5 sites. We compared each site with the averages in order to isolate each site's most anomalous responses. Major operational problems were independently identified by workgroups at each site. Cultural consensus analysis performance was then evaluated by comparison with workgroup results. PARTICIPANTS: Twenty patients, 10 residents, 10 faculty, members, and 10 administrators at each site completed the CCA. Workgroups included at minimum: a patient, resident, faculty member, nurse, and receptionist or clinic administrator. APPROACH: Cultural consensus analysis was performed at each site. Problems were identified by multidisciplinary workgroups, prioritized by anonymous multivoting, and confirmed by limited field observations and interviews. Cultural consensus analysis results were compared with workgroup results. RESULTS: The CCA detected systematic, group-specific preference differences at each site. These were moderately to strongly associated with the problems independently identified by the workgroups. The CCA proved to be a useful tool for exploring the problems in depth and for detecting previously unrecognized problems. CONCLUSIONS: This CCA worked in multiple VA sites. It may be adapted to work in other settings or to better detect other clinic problems.

Evaluation of a worksheet to structure teaching and learning outpatient internal medicine.

The Worksheet for Ambulatory Medicine (WAM) is an educational tool designed to enhance teaching and learning outpatient internal medicine. It was developed to identify student learning needs, focus teaching, and structure educational and patient care activities in a clinic setting. The purpose of the study was to assess the feasibility and educational value of using the WAM with medical students and preceptors. Sixty-five third- and fourth-year medical students and 12 supervising faculty at two university-based general medicine outpatient clinics used the WAM during required internal medicine clerkships. Students and faculty completed written evaluations. Results are reported as percentages of respondents agreeing or disagreeing with a variety of statements, and mean rating scores for several questions designed to assess the feasibility and educational value of using the worksheet. Student response rate was 89%; 83% found the WAM easy to use; 65% found it too structured. Half said the worksheet helped diagnostic decision making and note writing, and two-thirds thought it promoted careful thinking about differential diagnosis and aided in identifying learning issues. Some 56% said using the WAM motivated outside reading. Most students found it helpful for identifying patient agendas and focusing case presentations (61% and 67, respectively). Only 36% said the WAM helped with time management. Most preceptors thought the WAM helped identify earning issues, focus case presentations and clarify student expectations. There was less agreement among preceptors that it allowed them to demonstrate clinical reasoning or provide students with more autonomy in decision making. Nearly half the preceptors did not find it helpful with time management. Both students and preceptors rated the overall value and usefulness of the WAM as good to very good, and a majority recommended that others use it. Using the Worksheet for Ambulatory Medicine was feasible and educationally valuable for many third- and fourth-year medical students and their preceptor in a required ambulatory internal medicine clerkship.

A communication assessment and skill-building exercise (CASE) for first-year residents.

OBJECTIVE: Good communication skills are essential for residents entering postgraduate education programs. However, these skills vary widely among medical school graduates. This pilot program was designed to create opportunities for (1) teaching essential interviewing and communication skills to trainees at the beginning of residency, (2) assessing resident skills and confidence with specific types of interview situations, (3) developing faculty teaching and assessment skills, (4) encouraging collegial interaction between faculty and new trainees, and (5) guiding residency curricular development. DESCRIPTION: During residency orientation, all first-year internal medicine residents (n = 26) at the University of Minnesota participated in the communication assessment and skill-building exercise (CASE). CASE consisted of four ten-minute stations in which residents demonstrated their communication skills in encounters with standardized patients (SPs) while faculty members observed for specific skills. Faculty and SPs were oriented to the educational purposes and goals of their stations, and received instructions on methods of providing feedback to residents. With each station, residents were provided one and a half minutes of direct feedback by the faculty observer and the SP. The residents were asked to deal with an angry family member, to counsel for smoking cessation, to set a patient-encounter agenda, and to deliver bad news. A resident's performance was analyzed for each station, and individual profiles were created. All residents and faculty completed evaluations of the exercise, assessing the benefits and areas for improvement. DISCUSSION: Evaluations and feedback from residents and faculty showed that most of our objectives were accomplished. Residents reported learning important skills, receiving valuable feedback, and increasing their confidence in dealing with certain types of stressful communication situations in residency. The activity was also perceived as an excellent way to meet and interact with faculty. Evaluators found the experience rewarding, an effective method for assessing and teaching clinical skills, a faculty development experience for themselves in learning about structured practical skills exercises, and a good way to meet new interns. The residency program director found individual resident performance profiles valuable for identifying learning issues and for guiding curricular development. Time constraints were the most frequently cited area for improvement. The exercise became feasible by collaborating with the medical school Office of Education-Educational Development and Research, whose mission is to collaborate with faculty across the continuum of medical education to improve the quality of instruction and evaluation. The residency program saved considerable time, effort, and expense by using portions of the medical school's existing student skills-assessment programs and by using chief residents and faculty as evaluators. We plan to use CASE next year with a wider variety of physician-patient scenarios for interns, and to expand the program to include beginning second- and third-year residents. Also, since this type of exercise creates powerful feedback and assessment opportunities for instructors and course directors, and because feedback was so favorable from evaluators, we will encourage participation in CASE as part of our faculty educational development program.