Accessing perinatal substance use disorder care in your local community: A case study of an innovative hub and spoke network in western North Carolina.

INTRODUCTION: The incidence of substance use disorders (SUD) in the general population and in the pregnant person population has risen over the last 20 years. Concurrently, both perinatal and SUD care in rural areas is laden with access barriers including but not limited to geographical distance from potential treatment and stigma. An integrated outpatient perinatal substance use disorder (PSUD) clinic in an urban area in western North Carolina (WNC) found that patients who traveled further for prenatal care were less likely to continue seeking care in the postpartum period. Acknowledging that the risk of overdose increases in the postpartum period, the PSUD clinic utilized a hub and spoke model to promote healthcare accessibility. METHODS: The clinic adapted the Vermont hub and spoke model and the CHARM (Children and Recovering Mothers) collaborative. The urban hub in WNC has now developed eight spokes in rural communities. The hub provides education and technical assistance to the rural spokes, and the two engage in bidirectional referral pathways. This manuscript details the model and analyzes the existing strengths and barriers at two spokes, a family medicine Federally Qualified Health Center and a hospital affiliated obstetrics and gynecology practice and analyzes their process of implementation of integrated outpatient perinatal substance use care. RESULTS: Both spokes found coaching relationships and the sharing of resources such as clinical guidelines useful to begin prescribing buprenorphine for PSUD. Their context led one spoke to begin prescribing within one year while the other took two years. CONCLUSION: Comparing and contrasting these spokes serves to demonstrate that across many contexts, a hub and spoke model is a replicable intervention for rural perinatal substance use access to care barriers. Comparing the two spokes emphasizes the need for adaptation as well as standardization of the model to improve evidence-based PSUD care most effectively.

Psychological safety and accountability in longitudinal integrated clerkships: a dual institution qualitative study.

BACKGROUND: Psychological safety and accountability are frameworks to describe relationships in the workplace. Psychological safety is a shared belief by members of a team that it is safe to take interpersonal risks. Accountability refers to being challenged and expected to meet expectations and goals. Psychological safety and accountability are supported by relational trust. Relational continuity is the educational construct underpinning longitudinal integrated clerkships. The workplace constructs of psychological safety and accountability may offer lenses to understand students' educational experiences in longitudinal integrated clerkships. METHODS: We performed a qualitative study of 9 years of longitudinal integrated clerkship graduates from two regionally diverse programs-at Harvard Medical School and the University of North Carolina School of Medicine. We used deductive content analysis to characterize psychological safety and accountability from semi-structured interviews of longitudinal integrated clerkship graduates. RESULTS: Analysis of 20 graduates' interview transcripts reached saturation. We identified 109 discrete excerpts describing psychological safety, accountability, or both. Excerpts with high psychological safety described trusting relationships and safe learning spaces. Low psychological safety included fear and frustration and perceptions of stressful learning environments. Excerpts characterizing high accountability involved increased learning and responsibility toward patients. Low accountability included students not feeling challenged. Graduates' descriptions with both high psychological safety and high accountability characterized optimized learning and performance. CONCLUSIONS: This study used the workplace-based frameworks of psychological safety and accountability to explore qualitatively longitudinal integrated clerkship graduates' experiences as students. Graduates described high and low psychological safety and accountability. Graduates' descriptions of high psychological safety and accountability involved positive learning experiences and responsibility toward patients. The relational lenses of psychological safety and accountability may inform faculty development and future educational research in clinical medical education.

Addressing cannabis consumption among patients with hyperemesis gravidarum.

Severe nausea and vomiting of pregnancy and hyperemesis gravidarum affect up to 3% of all pregnant people, causing substantial maternal and neonatal morbidity, suffering, and financial cost. Evidence supports the association of cannabis consumption with symptoms of severe nausea and vomiting of pregnancy or hyperemesis gravidarum as the general public has come to believe that cannabis is a natural, safe antiemetic. Cannabis consumption in pregnancy is discouraged strongly by the Surgeon General of the United States and the American College of Obstetricians and Gynecologists because of evidence of potential harms. Symptoms of intractable, severe nausea and vomiting of pregnancy or hyperemesis gravidarum associated with cannabis consumption may be unrecognized cannabinoid hyperemesis syndrome, and this syndrome may be more common than previously thought. Cannabis consumption is especially detrimental when causing or exacerbating debilitating symptoms such as the intense, persistent, recurrent, or cyclic vomiting and associated dehydration and other sequelae of cannabinoid hyperemesis syndrome. Open discussion of cannabis consumption during pregnancy is very challenging for patients and maternity care providers in our current environment of variable legal status across states and variable degrees of personal and societal acceptance. Evidence-based medical knowledge, guidance, tools, and skills are needed to differentially diagnose and treat cannabinoid hyperemesis syndrome in pregnancy. Researchers, clinicians, and medical specialty organizations must work together to strengthen the evidence base and develop or refine the necessary guidelines and tools for maternity care provider skill development, and to increase public and patient awareness of cannabinoid hyperemesis syndrome, specifically during pregnancy.

What happy physicians have in common: A qualitative study of workplace perceptions of physicians with low burnout scores.

Introduction: Burnout is a phenomenon in the medical field that adversely affects patient care, physician retention, and physician well-being. The preponderance of burnout research has primarily focused on exploring what parts of medical practice and individual characteristics contribute to burnout. Our research aims to add to the growing body of evidence exploring what physicians who love their work have in common. Methods: Physician participants in this qualitative study were recruited through their local medical society from those who indicated a willingness to share tips for joy in practice. Potential participants were then screened for low probability of burnout using a validated single-item burnout inventory. Nine primarily mid- to late-career physicians engaged in semi-structured interviews and thematic analysis was used to analyze data. Of the interviewed physicians, five were practicing in the primary care specialties of family or internal medicine and four in specialties outside of primary care. Results: Six major themes arose from the nine interviews and included variety in work, a sense of empowerment, connection with patients, visible impact of one's work, feelings of community with coworkers and colleagues, and experiencing a sense of calling. Conclusion: While further research is needed to demonstrate the transferability of the themes from these interviews, an asset-rooted approach to physician wellness is a direction for research and intervention that deserves further attention. Focusing only on alleviating the factors that contribute to burnout is a worthy goal, but ignores the necessity of designing training systems and workplaces that are built to foster the elements of medicine that bring joy and fulfillment to practice.

Using a Community Engagement Approach to Enhance Contraception Awareness in Rural Western North Carolina.

BACKGROUND Unintended pregnancy rates remain higher than the national average in North Carolina. Although long-acting reversible contraception (LARC) use has reduced rates of unintended pregnancy, this contraceptive method is widely underused, often due to low community awareness. Boot Camp Translation is a community engagement process that promotes community awareness of evidence-based medical recommendations by designing culturally meaningful messages.METHODS We tested the feasibility of the Boot Camp Translation process to expand awareness about LARC in 2 rural Western North Carolina counties. After our intervention, we conducted surveys at 4 local clinics, asking patients if and where they saw LARC messages.RESULTS The recruited community members had a participation rate of 93% throughout the intervention. A local nurse practitioner, health department nursing supervisor, health educator, and pre-medical student collaborated with local community members to disseminate culturally meaningful messages about LARC through social media, a website, promotional items, posters, and sexual education talks at local schools. Among women surveyed, 48.9% saw LARC campaign messages and of those, 57% saw messages through social media posts. Post-intervention, 6 local schools implemented a comprehensive sexual education curriculum.LIMITATIONS Our pilot project was not designed to quantitatively assess the community reception to our intervention, our intervention's impact on community knowledge about LARC methods, or changes in contraception practices.CONCLUSIONS We have demonstrated the feasibility of implementing Boot Camp Translation as a tool to enhance public awareness of contraception. This community engagement method underscores the benefit of empowering community members in public health projects.

Association of Maternal Buprenorphine or Methadone Dose with Fetal Growth Indices and Neonatal Abstinence Syndrome.

OBJECTIVE: Our objective was to compare fetal growth and incidence of neonatal abstinence syndrome requiring treatment across pregnant women with opioid use disorders on two types and two dose categories of medication-assisted treatment. STUDY DESIGN: A retrospective cohort study was conducted in a comprehensive, perinatal program in western North Carolina comparing growth percentiles on third-trimester ultrasound and at birth, and diagnosis of neonatal abstinence syndrome requiring treatment. Singletons were exposed in utero to low- to moderate-dose buprenorphine (≤16 mg/day; n = 70), high-dose buprenorphine (≥17 mg/day; n = 36), low- to moderate-dose methadone (≤89 mg/day; n = 41), or high-dose methadone (≥90 mg/day; n = 74). Multivariate analysis of variance with posthoc Bonferroni comparisons (p ≤ 0.01) and multinomial logistic regressions (adjusted odds ratio, 99% confidence interval) were conducted. RESULTS: Differences in neonatal outcomes reached statistical significance for larger head circumference for buprenorphine doses (p = 0.01) and for longer length (p < 0.01) and lower odds of neonatal abstinence syndrome requiring treatment (p < 0.01) with low- to moderate-dose buprenorphine versus high-dose methadone. CONCLUSION: Among pregnant women using medication-assisted treatment for opioid use disorders, low- to moderate-dose buprenorphine (≤16 mg/day) was associated with the most favorable neonatal outcomes. However, more rigorous control of confounders with a larger sample is necessary to determine if low- to moderate-dose buprenorphine is the better treatment choice.

The association of cannabis use late in pregnancy with engagement and retention in perinatal substance use disorder care for opioid use disorder: A cohort comparison.

BACKGROUND: Prenatal use of cannabis and opioids are increasing and very concerning. Engagement and retention in comprehensive, perinatal substance use disorder (PSUD) care are associated with better outcomes for mothers and babies. We compared the characteristics and engagement in care among women with opioid use disorder who used cannabis late in pregnancy versus those who didn't. METHODS: The primary outcome, "overall engagement and retention in PSUD care" included: utilization of substance use treatment prenatally, negative screening/toxicology at delivery (excluding cannabis), and attendance at expected prenatal and postpartum visits. Cannabis use late in pregnancy was objectively assessed at delivery via maternal urine drug screen and/or neonatal meconium/cord toxicology. Between-group comparisons utilized chi square, t-test or Mann-Whitney. Associations were assessed using Spearman Rho and two multivariate, binary logistic regressions for cannabis use and the primary outcome. RESULTS: 18.0% (85/472) consumed cannabis late in pregnancy. Women of color, younger women, and those diagnosed with concurrent cannabis use disorder were more likely to consume cannabis. Engagement and retention in PSUD care was not associated with cannabis use, but rather, with prescribed pharmacotherapy for psychiatric disorders. The use of prescribed buprenorphine+naloxone was associated with cannabis avoidance late in pregnancy. CONCLUSIONS: Cannabis use late in pregnancy, compared to none, did not impact engagement and retention in our PSUD program. Adjunctive psychotropic medication and/or buprenorphine+naloxone prescription were associated with cannabis avoidance suggesting the use and interactions of pharmacotherapies in an opioid dependent population is complex. A shared decision-making process during PSUD care is warranted.

A Cohort Comparison of Differences Between Regional and Buncombe County Patients of a Comprehensive Perinatal Substance Use Disorders Program in Western North Carolina.

BACKGROUND Pregnant patients from rural counties of Western North Carolina face additional barriers when accessing comprehensive perinatal substance use disorders care at Project CARA as compared to patients local to the program in Buncombe County. We hypothesized regional patients would be less engaged in care.METHOD Using a retrospective cohort design, univariate analyses (χ2, t-test; P < .05) compared patients' characteristics, engagement in care, and delivery outcomes. Engagement in care, the primary outcome, was operationalized as: attendance at expected, program-specific prenatal and postpartum visits, utilization of in-house counseling, community-based and/or inpatient substance use disorders treatment, and maternal urine drug screen at delivery negative for illicit substances.RESULTS Regional patients (n = 324) were more likely than Buncombe County patients (n = 284) to have opioid [209 (64.5%) versus 162 (57.0%)] or amphetamine/methamphetamine use disorders (25 [7.7%] versus 13 [4.6%]), but less likely to have cannabis use (19 [5.9%] versus 38 [13.4%]; P = .009) and concurrent psychiatric disorders (214 [66.0%] versus 220 [77.5%]; P = .002). Engagement at postpartum visits was the significantly different outcome between patients (110/221 [49.8%] versus 146/226 [64.6%]; P = .002).LIMITATIONS Outcomes were available for 66.8% of regional and 79.6% of Buncombe County patients of one program in one predominately white, non-Hispanic region of the state.CONCLUSION Contrary to our hypothesis, regional and Buncombe County women engaged in prenatal care equally. However, a more formal transition into the postpartum period is needed, especially for regional women. A "hub-and-spokes" model that extends delivery of perinatal substance use disorders care into rural communities may be more effective for engagement retention.

Buprenorphine and Naloxone Versus Buprenorphine for Opioid Use Disorder in Pregnancy: A Cohort Study.

OBJECTIVE: To compare maternal and fetal outcomes among dyads prescribed buprenorphine and naloxone or buprenorphine during pregnancy. METHODS: Retrospective cohort study of patients with opioid use disorder obtaining care in a comprehensive, perinatal program. Patients utilized medication for opioid use disorder: a buprenorphine and naloxone combination product or buprenorphine monotherapy. The primary outcome was neonatal abstinence syndrome requiring treatment. Maternal secondary outcomes included: negative urine drug screen at delivery, obstetrical care attendance, primary cesarean delivery, and preterm delivery. Neonatal secondary outcomes included neonatal biometry, admission to neonatal intensive care, appropriate findings on cord toxicology, and length of stay. Univariate analyses included Chi square, Fisher exact, t-, or Mann-Whitney tests, as appropriate. Multivariate binary logistic regressions examined the association of type of buprenorphine product with diagnosis of neonatal abstinence syndrome requiring treatment and adjusted for variables significantly different in between-group comparisons and correlates of treatments and the primary outcome. RESULTS: The rate of neonatal abstinence syndrome was significantly higher (P = 0.007) among infants exposed in utero to buprenorphine versus buprenorphine and naloxone: 59/108 (54.6%) versus 30/85 (35.3%), respectively. The combined product, relative to the monoproduct, was associated with lower odds of neonatal abstinence syndrome: odds ratio (OR) = 0.453 (95% confidence interval [CI] 0.253-0.813; P = 0.008). Adjusting for dose of buprenorphine product at delivery, year of expected delivery, type of prescriber, diagnosis of hepatitis C, and preterm delivery negated these results: adjusted OR = 0.627 (95% CI 0.309-1.275). Secondary outcomes were similar. CONCLUSION: Compared with buprenorphine monotherapy, the combined buprenorphine and naloxone product was an acceptable alternative pharmacologic treatment for opioid use disorder during pregnancy.

Teaching Opioid Tapering Through Guided Instruction.

BACKGROUND AND OBJECTIVES: Given the current opioid epidemic, national practice guidelines and many state laws are shifting the treatment paradigm for chronic, noncancer pain to a judicious use of opioids. This has prompted a need to teach family medicine residents how to appropriately taper opioids. We created a multifaceted approach to integrate teaching of opioid tapering into a family medicine curriculum with an emphasis on guided instruction. We assessed the degree to which this curriculum affected guideline-concordant opioid prescribing within the family medicine practice. METHODS: A retrospective chart review of 707 patients on chronic opioid therapy (COT) for noncancer pain was conducted before and after the incorporation of a guided instruction experience to the residency curriculum. The primary outcomes included the number of patients on chronic opioids, the average morphine equivalent daily (MED) per patient, the percentage of patients on >50 MED or >90 MED, and the number of patients on concomitant benzodiazepines. RESULTS: Of the original 707 patients, 188 tapered off COT. Of those remaining on COT, the average MED did not change (53.4±76.9 vs 58.5+89.1, P=0.053). The percentage of patients on >50 MED and >90 MED decreased significantly (30.6% vs 25.0%, P=0.001; 19.4% vs 14.0%, P=0.027). The total number of patients on concomitant benzodiazepine decreased from 212 to 131. CONCLUSIONS: Providing opportunities for guided instruction with opioid tapering allowed for an increased concordance with national practice guidelines.

Evaluation of the need for a fracture liaison service in a patient-centered medical home.

OBJECTIVES: To evaluate the need for a fracture liaison service (FLS) based on postfracture care in a patient-centered medical home (PCMH). METHODS: Patients in a PCMH who presented to a local 763-bed community teaching hospital with fragility fracture of the hip, spine, or forearm between January 1, 2013, and December 31, 2014, were identified using ICD-9 codes. A retrospective chart review of inpatient and outpatient medical records 2 years before the fracture and 1 year afterward was conducted. The primary outcome was dual X-ray absorptiometry (DXA) scan utilization or pharmacotherapy for osteoporosis 6 months after fracture. RESULTS: One hundred eighty-two patients were identified, and 75 patients were included in the analysis. The median age of the cohort was 84 years, and 70.7% of patients were white women. Fragility fractures included hip fracture (42.7%), vertebral fracture (40.0%), and forearm fracture (17.3%). Six months after fracture, 30.7% of patients were prescribed prescription therapy for osteoporosis, and 6.7% had received a DXA scan. Although nearly all patients had a follow-up visit in the PCMH during the year after fracture, only 8.3% were seen in an established osteoporosis clinic. Twenty-three percent of patients were deceased at 1 year. CONCLUSIONS: More patients in this PCMH received a DXA scan or pharmacotherapy, or both, for osteoporosis 6 months after fragility fracture than observed nationally. However, approximately 70% of patients were undertreated. Incorporating principles of an FLS into an existing osteoporosis clinic is warranted.

Use of wearable sensors for pregnancy health and environmental monitoring: Descriptive findings from the perspective of patients and providers.

BACKGROUND: Wearable sensors and other smart technology may be especially beneficial in providing remote monitoring of sub-clinical changes in pregnancy health status. Yet, limited research has examined perceptions among pregnant patients and providers in incorporating smart technology into their daily routine and clinical practice. OBJECTIVE: The purpose of this study was to examine the perceptions of pregnant women and their providers at a rural health clinic on the use of wearable technology to monitor health and environmental exposures during pregnancy. METHODS: An anonymous 21-item e-survey was administered to family medicine or obstetrics and gynecology (n=28) providers at a rural health clinic; while a 21-item paper survey was administered to pregnant women (n=103) attending the clinic for prenatal care. RESULTS: Smartphone and digital technology use was high among patients and providers. Patients would consider wearing a mobile sensor during pregnancy, reported no privacy concerns, and felt comfortable sharing information from these devices with their physician. About seven out of 10 women expressed willingness to change their behavior during pregnancy in response to receiving personalized recommendations from a smartphone. While most providers did not currently use smart technologies in their medical practice, about half felt it will be used more often in the future to diagnose and remotely monitor patients. Patients ranked fetal heart rate and blood pressure as their top preference for health monitoring compared to physicians who ranked blood pressure and blood glucose. Patients and providers demonstrated similar preferences for environmental monitoring, but patients as a whole expressed more interests in tracking environmental measures compared to their providers. CONCLUSIONS: Patients and providers responded positively to the use of wearable sensor technology in prenatal care. More research is needed to understand what factors might motivate provider use and implementation of wearable technology to improve the delivery of prenatal care.

Effect of Morbid Obesity on Midurethral Sling Efficacy for the Management of Stress Urinary Incontinence.

OBJECTIVES: The aim of our study was to assess midurethral sling (MUS) failure rate in the morbidly obese (body mass index [BMI] ≥40 kg/m) population as compared with normal-weight individuals. Our secondary objective was to assess the difference in complication rates. METHODS: This is a retrospective cohort study. We included all patients who underwent a synthetic MUS procedure from January 1, 2008, to December 31, 2015, in our health system. Failure was defined as reported stress urinary incontinence symptoms or treatment for stress urinary incontinence. Variables collected were BMI; smoking status; comorbidities; perioperative (≤24 hours), short-term (≤30 days), and long-term (>30 days) complications; and follow-up time. Statistics include analysis of variance, χ test, logistic regression, Kaplan-Meier method, and Cox regression. RESULTS: There were 431 patients included in our analysis. Forty-nine patients were in class 3 with a BMI mean of 44.9 ± 5.07 kg/m. Median follow-up time was 52 months (range, 6-119 months). Class 3 obesity (BMI ≥40 kg/m) was the only group that had an increased risk of failure when compared with the normal-weight group (P = 0.03; odds ratio, 2.47; 95% confidence interval, 1.09-5.59). Obesity was not a significant predictor of perioperative, short-term, or long-term postoperative complications (P = 0.19, P = 0.28, and P = 0.089, respectively) after controlling for other comorbidities. CONCLUSIONS: Patients in the class 3 obesity group who are treated with an MUS are 2 times as likely to fail when compared with those in the normal-weight category on long-term follow-up with similar low complication rates.

Unexpected ICU Admission Is Associated with Pulmonary Complications but Not Increased Mortality; Rescue Is Essential for Optimal Patient Outcome.

ICU beds are in demand in large regional referral hospitals; therefore, nonintubated polytrauma patients are often admitted to general care (GC) wards. We hypothesized that trauma patients with Injury Severity Score (ISS) greater than 15 and unexpected ICU admission (U-ICU) after initial admission to GC had increased morbidity and mortality. We also hypothesized that those requiring U-ICU could be predicted based on admission parameters. This was a retrospective review of patients aged at least 18 years, admitted to GC with blunt trauma and ISS greater than 15 from April 2015 to March 2017. Demographics were collected along with injury patterns and complications. Statistics included chi-squared, Fisher's exact, Mann-Whitney, and t tests. Of 986 patients, 502 (50.9%) were directly admitted to GC. Prevalence of U-ICU was 9.8 per cent (49/502 patients). The only admission predictor of U-ICU was a history of myocardial infarction (8/49, 16.3%, vs 21/453, 4.6%, P = 0.001). Those with U-ICU had increased incidence of pneumonia, acute respiratory distress syndrome, and endotracheal intubation compared with GC, but there was no difference in overall mortality (3/49, 6.1% vs 18/453, 4.0%, P = 0.45). Half of all severely injured, nonintubated patients can be managed on the GC ward; however, 9.8 per cent of patients will require U-ICU admission for pulmonary complications. Admission history of myocardial infarction predicts those at risk. Severely injured patients with U-ICU admission have significant cardiopulmonary complications, but can be rescued with no increase in overall mortality.

Adaption and validation of the Working Alliance Inventory for General Practice: qualitative review and cross-sectional surveys.

BACKGROUND: Relational aspects of primary care are important, but we have no standard measure for assessment. The 'working alliance' incorporates elements of the therapeutic relationship, shared decision-making, goal setting and communication skills. The Working Alliance Inventory (short form) (WAI-SF) has been used in adult psychology, and a high score on the survey is associated with improved outcomes for clients. OBJECTIVE: To adapt the WAI-SF for use between GPs and patients and to test its concurrent validity with measures of shared decision-making and the doctor-patient relationship and discriminant validity with measures of social desirability. METHODS: Two rounds of online survey feedback from 55 GPs and 47 patients were used to adapt the WAI-SF-the WAI-GP. The tool was then completed by 142 patients in waiting rooms after seeing their GP and by 16 GPs at the end of their session. Concurrent validity with measures of shared decision-making and patient-doctor depth of relationship was determined using Spearman Rho correlations. Patients also completed two social desirability surveys, and discriminant validity with WAI-GP was assessed. RESULTS: Following feedback, the survey was re-worded to remove phrases that were perceived as judgmental or irrelevant. The patient measure of the WAI-GP was strongly correlated with Dyadic OPTION (rho = 0.705, P = 0.0001) and Patient-Doctor Depth of Relationship scale (rho = 0.591, P = 0.0001) and not with measures of social desirability. CONCLUSION: The psychometric properties of the WAI-GP support its use for measuring GP-patient alliance. Possibilities for use include assessing the influence of therapeutic alliance on the effectiveness of interventions.

Cultivating Country Doctors: Preparing Learners for Rural Life and Community Leadership.

BACKGROUND AND OBJECTIVES: Rural health disparities are growing, and medical schools and residency programs need new approaches to encourage learners to enter and stay in rural practice. Top correlates of rural practice are rural upbringing and rurally located training, yet preparation for rural practice plays a role. The authors sought to explore how selected programs develop learners' competencies associated with rural placement and retention: rural life, community engagement, and community leadership. METHODS: Qualitative, semistructured phone interviews (n=20) were conducted with faculty of medical schools or family medicine residencies across the United States, Canada, Australia, and South Africa in which success in training rural practitioners was identified in the literature or by leaders of the National Rural Health Association's Rural Medical Educators Group. Participants included 18 physician program directors, one nonphysician program administrator, and one PhD researcher who had studied rural preparation. Interview transcripts were read twice using an inductive process: first to identify themes, and then to identify specific strategies and quotes to exemplify each theme. RESULTS: Participants' recommendations for rural preparation were: (1) Be intentional about strategies to prepare learners for rural practice; (2) Identify and cultivate rural interest; (3) Develop confidence and competence to meet rural community needs; (4) Teach skills in negotiating dual relationships, leading, and improving community health; and (5) Fully engage rural host communities throughout the training process. CONCLUSIONS: Medical schools and residencies may increase the likelihood of producing rural physicians by implementing these experts' strategies. Educators may select strategies that mesh with the structure and location of their training program.

myTIPreport and Training for Independent Practice: A Tool for Real-Time Workplace Feedback for Milestones and Procedural Skills.

BACKGROUND: Few tools currently exist for effective, accessible delivery of real-time, workplace feedback in the clinical setting. OBJECTIVE: We developed and implemented a real-time, web-based tool for performance-based feedback in the clinical environment. METHODS: The tool (myTIPreport) was designed for performance-based feedback to learners on the Accreditation Council for Graduate Medical Education (ACGME) Milestones and procedural skills. "TIP" stands for "Training for Independent Practice." We implemented myTIPreport in obstetrics and gynecology (Ob-Gyn) and female pelvic medicine and reconstructive surgery (FPMRS) programs between November 2014 and May 2015. Residents, fellows, teachers, and program directors completed preimplementation and postimplementation surveys on their perceptions of feedback. RESULTS: Preimplementation surveys were completed by 656 participants of a total of 980 learners and teachers in 19 programs (12 Ob-Gyn and 7 FPMRS). This represented 72% (273 of 378) of learners and 64% (383 of 602) of teachers. Seventy percent of participants (381 of 546) reported having their own individual processes for real-time feedback; the majority (79%, 340 of 430) described these processes as informal discussions. Over 6 months, one-third of teachers and two-thirds of learners used the myTIPreport tool a total of 4311 times. Milestone feedback was recorded 944 times, and procedural feedback was recorded 3367 times. Feedback addressed all ACGME Milestones and procedures programmed into myTIPreport. Most program directors reported that tool implementation was successful. CONCLUSIONS: The majority of learners successfully received workplace feedback using myTIPreport. This web-based tool, incorporating procedures and ACGME Milestones, may be an important transition from other feedback formats.