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INTRODUCTION: Adverse childhood experiences (ACEs) are strongly correlated with many of the most common causes of preventable illness, preventable death, and health disparities. In January 2020, California launched the first statewide initiative to integrate ACE screening throughout its Medicaid system. A key element of the initiative was the California ACEs Learning and Quality Improvement Collaborative, a 48-clinic, 16-month learning collaborative. This evaluation aimed to determine whether developing a trauma-informed environment of care was associated with uptake of ACE screening. METHODS: Participants included 40 of 48 clinics that participated in the statewide learning collaborative. Clinics completed an assessment of progress in 5 essential components of trauma-informed health care at baseline and 1-year follow-up. Clinics tracked data on ACE screens completed on an ongoing basis and submitted data quarterly. A hierarchical linear model was used to examine the association between change in readiness for trauma-informed health care and change in quarterly screens. RESULTS: Readiness for trauma-informed health care increased for all participating clinics over the course of the learning collaborative. The average number of quarterly screens also increased, with considerable variability among clinics. Clinics with larger increases in readiness for trauma-informed health care had larger increases in quarterly screens. DISCUSSION: The findings align with long-standing recommendations for trauma screening to occur in the context of trauma-informed environments of care. CONCLUSION: A trauma-informed clinic is the foundation for successful adoption of ACE screening. ACE screening initiatives should include education and sufficient support for clinics to embrace a trauma-informed systems change process.
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Experiencias Adversas de la Infancia , Humanos , Aprendizaje , Atención a la SaludRESUMEN
PURPOSE: To understand clinician and clinical staff perspectives on the implementation of routine Adverse Childhood Experience (ACE) screening in pediatric primary care. METHODS: We conducted a qualitative evaluation in 5 clinics in Los Angeles County, California, using 2 rounds of focus group discussions: during an early phase of the initiative, and 7 months later. In the first round, we conducted 14 focus group discussions with 67 participants. In the second round, we conducted 12 focus group discussions with 58 participants. Participants comprised clinic staff involved in ACE screening, including frontline staff that administer the screening, medical clinicians that use screening to counsel patients and make referrals, and psychosocial support staff who may receive referrals. RESULTS: Themes were grouped into 3 categories: (1) screening acceptability and perceived utility, (2) implementation and quality improvement, and (3) effects of screening on patients and clinicians. Regarding screening acceptability and perceived utility, clinicians generally considered ACE screening to be acceptable and useful. In terms of implementation and quality improvement, significant barriers included: insufficient time for screening and response, insufficient training, and lack of clarity about referral networks and resources that could be offered to patients. Lastly, regarding effects of screening, clinicians expressed that ACE screening helped elicit important patient information and build trust with patients. Further, no adverse events were reported from screening. CONCLUSIONS: Clinic staff felt ACE screening was feasible, acceptable, and beneficial within pediatric care settings to improve trauma-informed care and that ACE screening could be strengthened by addressing time constraints and limited referral resources.
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Experiencias Adversas de la Infancia , Humanos , Niño , Los Angeles , Instituciones de Atención Ambulatoria , Grupos Focales , Derivación y ConsultaRESUMEN
INTRODUCTION: This qualitative research study explored the perspectives of adolescents, 12 to 19-years-old, and caregivers of children under 12-years-old on the acceptibility of adverse childhood experiences (ACEs) screenings in five pediatric clinics. METHOD: A constructivist grounded theory approach was utilized. One-on-one semistructured phone interviews were conducted with 44 adolescents and 95 caregivers of children less than 12 years old. Interviews were analyzed using thematic analysis. RESULTS: Most participants reported feeling comfortable discussing ACEs with their providers. Some reported that screening helped build trust. Others expressed privacy concerns and did not receive information about the reason for screening. Adolescent patients shared conflicting feelings-of both comfort and discomfort. Caregivers attending to multiple children, foster parents, and monolingual Spanish speakers disclosed unique challenges to ACEs screening. We found no evidence of lasting adverse effects. DISCUSSION: Participants generally found ACEs screenings acceptable. Some adolescents identified benefits from the experience. However, clinics planning to adopt routine ACEs screening should ensure clear messaging on why screening is occurring, anticipate and address privacy concerns, and adopt workflows to discuss screening results.
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Experiencias Adversas de la Infancia , Cuidadores , Adolescente , Niño , Humanos , Adulto Joven , Padres , Investigación CualitativaRESUMEN
PROBLEM: Dismantling structural racism is essential to achieving health equity, but there is little guidance for medical educators who wish to teach learners to recognize and confront structural racism. APPROACH: Critical consciousness provides a framework to identify and dismantle structural racism. Using a critical consciousness approach, the authors developed a novel 5-day travel experience to the American South for medical residents and faculty to explore the history and legacy of structural racism and the Civil Rights Movement. The purpose of the travel was to examine the connection between structural racism, especially anti-Black racism, and health disparities to better address health inequities within the participants' own home environment. Throughout the trip, faculty leaders applied principles of cultural humility and techniques from critical pedagogy, including recognizing the value of everyone in the room, creating cognitive disequilibrium, and promoting authentic dialogue. OUTCOMES: End-of-week surveys revealed that the trip was well received. Organizers learned important lessons related to faculty and resident dynamics, race-based affinity group meetings, and the respectful use of stories as a tool for learning. Post-trip surveys at 1, 6, and 12 months revealed 3 major themes: participants experienced (1) transformed understanding of systemic racism, (2) increased motivation and bravery to act when witnessing interpersonal and structural racism, and (3) increased practice of cultural humility. NEXT STEPS: Cultural humility and critical pedagogy can be used with travel to support learners in recognizing and confronting structural racism. The application of such techniques should be explored in local learning environments to foster commitment and action toward dismantling structural racism. In teaching structural racism, medical educators must be willing to consider new ways of teaching and learning.
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Educación Médica/métodos , Disparidades en Atención de Salud/etnología , Racismo/prevención & control , Viaje/psicología , Estado de Conciencia/ética , Coraje , Docentes/educación , Docentes/estadística & datos numéricos , Equidad en Salud , Disparidades en Atención de Salud/estadística & datos numéricos , Humanos , Internado y Residencia/estadística & datos numéricos , Liderazgo , Motivación , Evaluación de Resultado en la Atención de Salud , Aprendizaje Basado en Problemas/métodos , Racismo/psicología , Encuestas y Cuestionarios/estadística & datos numéricosAsunto(s)
Redes Comunitarias/organización & administración , Disparidades en Atención de Salud/organización & administración , Práctica Asociada/organización & administración , Salud Poblacional/estadística & datos numéricos , Medicina de Precisión/métodos , Humanos , Comunicación Interdisciplinaria , Estados Unidos , Poblaciones VulnerablesRESUMEN
Most academic health sciences centers offer faculty leadership development programs (LDPs); however, the outcomes of LDPs are largely unknown. This article describes perspectives from our 12-year experience cultivating a formal faculty LDP within an academic health center and longitudinal outcomes of our LDP. Responding to faculty concerns from University of California San Francisco's (UCSF) 2001 Faculty Climate Survey, UCSF established the UCSF-Coro Faculty Leadership Collaborative (FLC) in 2005. The FLC focused on building leadership skills using a cohort-based, experiential, interactive and collaborative learning approach. From 2005 to 2012, FLC has conducted training for 136 graduates over 7 cohorts with 97.6% completion rate. FLC faculty participants included 64% women and 13% underrepresented minority (URM). The proportions of graduates attaining leadership positions within UCSF such as deans or department chairs among all, URM, and women URM graduates were 9.6%, 33.3% and 45.5%, respectively. A 2013 online survey assessed 2005-2012 graduates' perceived impacts from 8 months to 8 years after program completion and showed 91.7% of survey respondents felt the program both increased their understanding of UCSF as an organization and demonstrated the University's commitment to foster faculty development. Qualitative results indicated that graduates perceived benefits at individual, interpersonal, and organizational levels. Though we did not directly assess impact on faculty recruitment and retention, the findings to date support cohort-based experiential learning in faculty leadership training development.
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Docentes/organización & administración , Liderazgo , Desarrollo de Personal/organización & administración , Adulto , Docentes Médicos/organización & administración , Femenino , Humanos , Masculino , Grupos Minoritarios , Desarrollo de Programa , San FranciscoRESUMEN
BACKGROUND: While leadership training is increasingly incorporated into residency education, existing assessment tools to provide feedback on leadership skills are only applicable in limited contexts. OBJECTIVE: We developed an instrument, the Leadership Observation and Feedback Tool (LOFT), for assessing clinical leadership. METHODS: We used an iterative process to develop the tool, beginning with adapting the Leadership Practices Inventory to create an open-ended survey for identification of clinical leadership behaviors. We presented these to leadership experts who defined essential behaviors through a modified Delphi approach. In May 2014 we tested the resulting 29-item tool among residents in the internal medicine and pediatrics departments at 2 academic medical centers. We analyzed instrument performance using Cronbach's alpha, interrater reliability using intraclass correlation coefficients (ICCs), and item performance using linear-by-linear test comparisons of responses by postgraduate year, site, and specialty. RESULTS: A total of 377 (of 526, 72%) team members completed the LOFT for 95 (of 519, 18%) residents. Overall ratings were high-only 14% scored at the novice level. Cronbach's alpha was 0.79, and the ICC ranged from 0.20 to 0.79. Linear-by-linear test comparisons revealed significant differences between postgraduate year groups for some items, but no significant differences by site or specialty. Acceptability and usefulness ratings by respondents were high. CONCLUSIONS: Despite a rigorous approach to instrument design, we were unable to collect convincing validity evidence for our instrument. The tool may still have some usefulness for providing formative feedback to residents on their clinical leadership skills.
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Competencia Clínica , Evaluación Educacional/métodos , Internado y Residencia/métodos , Liderazgo , Centros Médicos Académicos , California , Colorado , Retroalimentación , Humanos , Medicina Interna/educación , Pediatría/educación , Reproducibilidad de los ResultadosRESUMEN
INTRODUCTION: Stemming from an initiative launched at the University of California, San Francisco, School of Medicine's retreat in 2014, a group of 15 senior faculty and administrators convened to explicitly discuss strategies for creating an institutional culture of leadership. The group agreed to focus on improving a foundational skill involved in almost all leadership activities: running effective meetings. Meetings are necessary to advance institutional vision and growth. Moreover, meetings also can be detrimental if not run effectively, leading to lost productivity and meeting fatigue. METHODS: A working group developed and disseminated a workshop for learners, faculty, and administrators to create an institutional culture where meetings are interactive and transformational events. The resulting Meeting Optimization Program (MOP) is a 75- to 90-minute workshop that contains the key elements of effective meetings culled from existing literature and resources. MOP includes interactive discussion and a role-play to allow participants to practice effective meeting skills. The toolkit includes a facilitator guideline and a companion checklist of skills and resources. RESULTS: Working group members cofacilitated workshops for a variety of divisions across the campus. Participants rated the workshop highly for achieving its goal, for its overall effectiveness, and for the general format. Several participants became facilitators in a modified train-the-trainer model. Feedback highlighted the need for another iteration of the workshop focusing on facilitation. DISCUSSION: Creating change in complex systems inevitably involves meetings. Using MOP, institutions can empower their members with the tools to have effective meetings.
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Educational collaboratives offer a promising approach to disseminate educational resources and provide faculty development to advance residents' training, especially in areas of novel curricular content; however, their impact has not been clearly described. Advocacy training is a recently mandated requirement of the Accreditation Council for Graduate Medical Education that many programs struggle to meet.The authors describe the formation (in 2007) and impact (from 2008 to 2010) of 13 California pediatric residency programs working in an educational collaboration ("the Collaborative") to improve advocacy training. The Collaborative defined an overarching mission, assessed the needs of the programs, and mapped their strengths. The infrastructure required to build the collaboration among programs included a social networking site, frequent conference calls, and face-to-face semiannual meetings. An evaluation of the Collaborative's activities showed that programs demonstrated increased uptake of curricular components and an increase in advocacy activities. The themes extracted from semistructured interviews of lead faculty at each program revealed that the Collaborative (1) reduced faculty isolation, increased motivation, and strengthened faculty academic development, (2) enhanced identification of curricular areas of weakness and provided curricular development from new resources, (3) helped to address barriers of limited resident time and program resources, and (4) sustained the Collaborative's impact even after formal funding of the program had ceased through curricular enhancement, the need for further resources, and a shared desire to expand the collaborative network.
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Defensa del Niño/educación , Conducta Cooperativa , Educación de Postgrado en Medicina/organización & administración , Internado y Residencia/organización & administración , Relaciones Interprofesionales , Defensa del Paciente/educación , Pediatría/educación , Actitud del Personal de Salud , California , Niño , Curriculum , Educación de Postgrado en Medicina/métodos , Docentes Médicos , Humanos , Internado y Residencia/métodos , Desarrollo de Programa , Evaluación de Programas y Proyectos de SaludRESUMEN
AIM: Adolescents in the juvenile justice system are particularly susceptible to high rates of co-occurring health-risk behaviors, while at the same time lacking access to the healthcare system. METHODS: A verbal questionnaire was administered from December 2009 to June 2010 to youth between the ages of 13-17 years old, who had previously been detained in an urban juvenile detention facility in California. RESULTS: A total of 50 participants were enrolled in the study (40% female, 60% male, 16 years mean age, 80% Black, 18% Latino, 2% White). The mean time post-detention was 15 months, and the mean time in detention was 4 months. Our study provides evidence that adolescents exiting juvenile detention in the United States are interested in gaining access to healthcare providers but perceive lack of insurance and transportation as barriers to care. These barriers need to be addressed in order to facilitate access to healthcare services for this underserved and at-risk population of youth.
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Criminales , Accesibilidad a los Servicios de Salud , Aceptación de la Atención de Salud , Atención Individual de Salud/estadística & datos numéricos , Adolescente , California , Femenino , Humanos , Seguro de Salud , Delincuencia Juvenil , Masculino , Encuestas y Cuestionarios , TransportesRESUMEN
Physician-leaders are needed to address the widening gap in health disparities in an increasingly complex health care system. To be effective leaders, physicians need specific training; yet despite its importance, leadership training is rarely addressed during graduate medical education. As a result, most physician leadership training occurs after residency training. To address this gap in medical education, in 2004 the authors developed the Pediatric Leadership for the Underserved (PLUS) program at the University of California, San Francisco. The PLUS program incorporates leadership development into the framework of standard clinical training by providing specific sessions in personal leadership development and in related skills such as team building, negotiation, and conflict management. Leadership training is explicitly tied to clinical experiences to maximize relevance and opportunities for "real-time" application of new skills and knowledge. In addition, the curriculum includes sessions to develop and implement a three-year longitudinal child health project. Trainees are organized into advising groups to provide structured faculty and peer-peer advising. Key lessons learned in the implementation include the importance of having a skill-based, rather than a topic-based curriculum, and of exposing trainees to concrete examples of the many career paths of physician-leaders. Early outcomes from 2004 to 2009 include program evaluation data, trainee accomplishments, and postgraduate careers. This paper aims to inform other training programs about the development and feasibility of a residency program that incorporates leadership and underserved medicine curricula into the framework of standard clinical training.
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Educación de Postgrado en Medicina/tendencias , Internado y Residencia , Liderazgo , Pediatría/educación , Competencia Clínica , Curriculum , Difusión de Innovaciones , Humanos , Área sin Atención Médica , Desarrollo de Programa , Evaluación de Programas y Proyectos de Salud , San FranciscoAsunto(s)
Educación de Pregrado en Medicina/métodos , Evaluación Educacional/métodos , Microcomputadores/estadística & datos numéricos , California , Servicios de Salud Comunitaria/organización & administración , Documentación , Educación en Salud/organización & administración , Humanos , Internet , RegistrosRESUMEN
OBJECTIVE: Residency programs with postcall afternoon continuity clinics violate the new Accreditation Council for Graduate Medical Education (ACGME) limitations on resident duty hours. We evaluated housestaff experience with a pilot intervention that replaced postcall continuity clinics with evening continuity clinics. METHODS: We began this pilot program at one continuity clinic site for pediatric residents. Instead of postcall clinics, residents had evening continuity clinic added to a regular clinic day when they were neither postcall nor on call. At 5 and 11 months, we surveyed housestaff satisfaction and experience with the evening clinics, particularly in comparison to postcall clinics. RESULTS: Nineteen of 23 pediatric residents participated in the pilot program. Twenty-two and 17 residents completed the 5- and 11-month follow-up surveys, respectively. A significantly greater proportion of residents rated their overall satisfaction with evening clinic as good/outstanding (16/18, 89%) compared with postcall clinic (2/19, 11%) at the 5-month survey (P<.01). Resident preference for evening clinic over postcall clinic persisted but was not statistically significant at 11 months (P =.05), and overall satisfaction with evening clinic was unchanged from the 5- and 11-month surveys (P =.64). All areas of patient care, medical education, and clinic infrastructure were better or equal in evening clinic in comparison to postcall clinic except for continuity of preceptors and access to medical services. CONCLUSION: Housestaff had greater satisfaction and a better clinic experience with evening clinic versus postcall clinic. Evening continuity clinic is a viable solution to meeting the ACGME work hour limitations while preserving housestaff primary care education.