Design and pilot test of an implicit bias mitigation curriculum for clinicians.

Introduction: Clinician implicit racial bias (IB) may lead to lower quality care and adverse health outcomes for Black patients. Educational efforts to train clinicians to mitigate IB vary widely and have insufficient evidence of impact. We developed and pilot-tested an evidence-based clinician IB curriculum, "REACHing Equity." Methods: To assess acceptability and feasibility, we conducted an uncontrolled one-arm pilot trial with post-intervention assessments. REACHing Equity is designed for clinicians to: (1) acquire knowledge about IB and its impact on healthcare, (2) increase awareness of one's own capacity for IB, and (3) develop skills to mitigate IB in the clinical encounter. We delivered REACHing Equity virtually in three facilitated, interactive sessions over 7-9 weeks. Participants were health care providers who completed baseline and end-of-study evaluation surveys. Results: Of approximately 1,592 clinicians invited, 37 participated, of whom 29 self-identified as women and 24 as non-Hispanic White. Attendance averaged 90% per session; 78% attended all 3 sessions. Response rate for evaluation surveys was 67%. Most respondents agreed or strongly agreed that the curriculum objectives were met, and that REACHing Equity equipped them to mitigate the impact of implicit bias in clinical care. Participants consistently reported higher self-efficacy for mitigating IB after compared to before completing the curriculum. Conclusions: Despite apparent barriers to clinician participation, we demonstrated feasibility and acceptability of the REACHing Equity intervention. Further research is needed to develop objective measures of uptake and clinician skill, test the impact of REACHing Equity on clinically relevant outcomes, and refine the curriculum for uptake and dissemination.ClinicalTrials.gov ID: NCT03415308.

Race differences in patient trust and distrust from audio-recorded cardiology encounters.

OBJECTIVE: Many have reported racial disparities in self-reported trust in clinicians but have not directly assessed expressions of trust and distrust in physician-patient encounters. We created a codebook to examine racial differences in patient trust and distrust through audio-recorded cardiologist-patient interactions. METHODS: We analyzed data from a randomized controlled trial of audio-recorded outpatient cardiology encounters (50 White and 51 Black patients). We created a codebook for trust and distrust that was applied to recordings between White cardiologists and White and Black patients. We assessed differences in trust, distrust, and guardedness while adjusting for patient age, sex, and first appointment with the cardiologist. RESULTS: Compared to White patients, Black patients had significantly lower expressions of trust ([IRR] [95 % CI]: 0.59 [0.41, 0.84]) and a significantly lower mean guarded/open score ([ß] [95 % CI] -0.38 [-0.71, -0.04]). There was no statistically significant association between race and odds of at least one distrustful expression (OR [95 % CI] 1.36 [0.37, 4.94]). CONCLUSION AND PRACTICE IMPLICATIONS: We found that coders can reliably identify patient expressions of trust and distrust rather than relying on problematic self-reported measures. Results suggest that White clinicians can improve their communication with Black patients to increase expressions of trust.

Design and Evaluation of an Interprofessional Preceptor Development Mini-Fellowship Program.

INTRODUCTION: Health professions preceptors require skills and knowledge to effectively meet the educational needs of interprofessional students in clinical environments. We implemented a mini-fellowship program to enhance the knowledge, skills, and self-efficacy of preceptors teaching students and applying quality improvement (QI) methods across disciplines and patient care settings. METHOD: The design, implementation, and evaluation of the program were informed by the faculty development literature, principles of adult learning, and preceptor needs. The 3-day program included workshops on curriculum design, clinical teaching methods, QI, social determinants of health, cultural humility, and interprofessional teamwork. Quantitative and qualitative evaluation methods were used including preprogram and postprogram knowledge and self-efficacy surveys, along with end-of-session and program evaluations. RESULTS: Five annual cohorts involving 41 preceptors with varied demographics, professions, and clinical practices completed the mini-fellowship program. Participants' percentage of items answered correctly on a QI knowledge test increased from 79.2% (pretest) to 85.5% (post-test), a gain of 6.3% (90% CI: 2.9-9.7%; P < .003). The average QI self-efficacy scores improved from 2.64 to 3.82, a gain of 1.18 points on a five-point scale (P < .001). The average education/teaching self-efficacy increased from 2.79 to 3.80 on a five-point scale (P < .001). Ultimately, 94% would recommend the program to other preceptors. DISCUSSION: An interprofessional preceptor development program designed to train clinicians to effectively teach in the clinical setting and to conduct QI projects with students was achievable and effective. This program can serve as a model for academic centers charged with training future health care workers and supporting their community-based preceptors' training needs.

Effect of a Coaching Intervention to Improve Cardiologist Communication: A Randomized Clinical Trial.

Importance: Communication between cardiologists and patients can significantly affect patient comprehension, adherence, and satisfaction. To our knowledge, a coaching intervention to improve cardiologist communication has not been tested. Objective: To evaluate the effect of a communication coaching intervention to teach evidence-based communication skills to cardiologists. Design, Setting, and Participants: This 2-arm randomized clinical trial was performed at outpatient cardiology clinics at an academic medical center and affiliated community clinics, and from February 2019 through March 2020 recruited 40 cardiologists and audio recorded 161 patients in the preintervention phase and 240 in the postintervention phase. Data analysis was performed from March 2022 to January 2023. Interventions: Half of the cardiologists were randomized to receive a coaching intervention that involved three 1:1 sessions, 2 of which included feedback on their audio-recorded encounters. Communication coaches taught 5 skills derived from motivational interviewing: (1) sitting down and making eye contact with all in the room, (2) open-ended questions, (3) reflective statements, (4) empathic statements, and (5) "What questions do you have?" Main Outcomes and Measures: Coders unaware of study arm coded these behaviors in the preintervention and postintervention audio-recorded encounters (objective communication). Patients completed a survey after the visit to report perceptions of communication quality (subjective communication). Results: Analysis included 40 cardiologists (mean [SD] age, 47 [9] years; 7 female and 33 male) and 240 patients in the postintervention phase (mean [SD] age, 58 [15] years; 122 female, 118 male). When controlling for preintervention behaviors, cardiologists in the intervention vs control arm were more likely to make empathic statements (intervention: 52 of 117 [44%] vs control: 31 of 113 [27%]; P = .05); to ask, "What questions do you have?" (26 of 117 [22%] vs 6 of 113 [5%]; P = .002); and to respond with empathy when patients expressed negative emotions (mean ratio of empathic responses to empathic opportunities, 0.50 vs 0.20; P = .004). These effects did not vary based on patient or cardiologist race or sex. We found no arm differences for open-ended questions or reflective statements and were unable to assess differences in patient ratings due to ceiling effects. Conclusions and Relevance: In this randomized clinical trial, a communication coaching intervention improved 2 key communication behaviors: expressing empathy and eliciting questions. Empathic communication is a harder-level skill that may improve the patient experience and information comprehension. Future work should explore how best to assess the effect of communication coaching on patient perceptions of care and clinical outcomes and determine its effectiveness in larger, more diverse samples of cardiologists. Trial Registration: ClinicalTrials.gov Identifier: NCT03464110.

Do Physician Assistant Students Use Retrieval-Based Strategies While Studying?

INTRODUCTION: Research on learning indicates that active retrieval of information (ie, testing) enhances student retention of knowledge, yet, it is underutilized by learners. This research investigated physician assistant (PA) students' study strategies and the extent to which retrieval-based strategies (RBS) are used. METHODS: A survey instrument adapting items from Hartwig and Dunlosky's Study Habits Survey was administered to first-year PA students to investigate their study behaviors over a 4-week time frame in preparation for multiple-choice exams. RESULTS: Seventy-eight students (88%) completed the survey. The most common study strategies were reviewing lecture slide decks (83%), reading notes (78%), and taking notes (73%). Retrieval-based study strategies most often used were practicing test questions (38%) and creating questions and responding to them (12%). DISCUSSION: Many PA students are underutilizing retrieval-based study strategies and might benefit from more awareness of this learning approach as well as faculty guidance about how to incorporate it into their exam preparation.

The Impact of Racial Bias in Patient Care and Medical Education: Let's Focus on the Educator.

Introduction: Racial bias in health care is well documented. Research shows the presence of racial bias among health care providers. There is a paucity of workshops focused on racial bias effects in health professions educators. Method: Two to three workshops were delivered to a diverse group of clinical educators from three programs at a major academic institution. Each workshop included a brief multimedia presentation followed by a facilitated group discussion. Participants completed the online Implicit Association Test (IAT), a baseline demographic questionnaire, and a brief post-then-pre questionnaire. Results: Twenty-four faculty participated in the study (six physicians, eight nurse practitioners, 10 physician assistants). Nineteen (90%) were women, 18 (86%) were White, nine (43%) had more than 10 years of experience as educators, and seven (35%) had previously participated in a biases program. Seventeen completed the IAT. Sixteen educators agreed or strongly agreed that bias has a significant impact on patients' outcomes at the end of the workshop compared to 17 before the workshop. Seventeen educators agreed or strongly agreed that recognizing their own racial bias would positively alter their teaching practice after the workshop compared to 15 before the workshop. Discussion: This series of workshops was created to fill a gap regarding the impact of racial bias on patient outcomes, health disparities, and health professions education. The impact of racial bias in health professions education and the long-term impact of awareness and knowledge of racial bias in education are areas needing further evaluation.

An innovative educational clinical experience promoting geriatric exercise.

Formal educational training in physical activity promotion is relatively sparse throughout the medical education system. The authors describe an innovative clinical experience in physical activity directed at medical clinicians on a geriatrics rotation. The experience consists of a single 2 1/2 hour session, in which learners are partnered with geriatric patients engaged in a formal supervised exercise program. The learners are guided through an evidence-based exercise regimen tailored to functional status. This experience provides learners with an opportunity to interact with geriatric patients outside the hospital environment to counterbalance the typical geriatric rotation in which geriatric patients are often seen in clinics or hospitals. In this experience, learners are exposed to fit and engaged geriatric patients successfully living in the community despite chronic or disabling conditions. A survey of 105 learners highlighted positive responses to the experience, with 96% of survey respondents indicating that the experience increased their confidence in their ability to serve as advocates for physical activity for older adults, and 89.5% of responders to a follow-up survey indicating that the experience changed their perception of geriatric patients. Modifications to the experience, implemented at partnering facilities are described. The positive feedback from this experience warrants consideration for implementation in other settings.

Increasing Physician Assistant Students' Team Communication Skills and Confidence Throughout Clinical Training.

PURPOSE: An intervention was designed to increase physician assistant students' team communication skills using the Situation-Background-Assessment-Recommendation (SBAR) tool. METHODS: A variety of learning activities were implemented longitudinally over 9 months of clinical education. Instructional activities included an interactive lecture, deliberate practice of SBAR at clinical training sites, self-assessment, and small group discussion. Evaluation involved survey of students' perceived learning outcomes and direct observation of students' proficiency using SBAR during a simulated patient encounter. RESULTS: At the beginning of their clinical training, many students (75%) did not have a structured tool for communicating on health care teams. The SBAR tool was readily understood by students following a lecture (89%) and increased their confidence in communicating with preceptors (62%-83%) and nonpreceptors (62%-79%). A majority of students proficiently demonstrated the SBAR components (82%-86%) at the conclusion of the program. CONCLUSION: This approach can be adopted and adapted by other programs aiming to teach and evaluate SBAR and other team skills to better prepare new health professionals to effectively communicate on health care teams.

Design and Evaluation of an Interdisciplinary Health Disparities Research Curriculum.

BACKGROUND: Disparities in health and healthcare are widely documented for underrepresented racial and ethnic populations across a spectrum of diseases and care settings. An evidence base for addressing racial and ethnic disparities in health and healthcare requires investigators trained to conduct health disparities research. OBJECTIVE: To increase knowledge, stimulate interest, teach skills to evaluate and conduct, and foster collaborations in health disparities research. DESIGN: We designed, implemented and evaluated a Health Disparities Research Curriculum (HDRC). Participants were early-stage investigators. INTERVENTION: HDRC included twelve monthly sessions during 2015-2016. Instructors were mostly HDR investigators. Sessions combined didactic presentations, discussions, small group activities, and participant presentations. MEASURES: Pre- and post-surveys to assess participants' perceptions of knowledge and skills. RESULTS: Of 21 enrollees, 13 were from under-represented groups and 14 were women. Four reported some prior training in HDR, and 12 reported currently conducting HDR. Among the 12 participants who completed both the pre and post HDRC survey, initially the most commonly cited barriers to pursuing HDR were lack of knowledge (N = 6) and funding (N = 7). In the post-survey, the number citing lack of knowledge decreased (N = 2) and the number listing lack of funding increased (N = 9). There were increases in the number of participants reporting increased knowledge of HDR methods (pre-post: 4 vs. 8) and competence to design (3 vs. 7) and implement (2 vs. 9) HDR research. CONCLUSIONS: The Duke HDRC augments efforts to reduce health disparities by providing training in HDR for young investigators. Our data indicate that the course was feasible, well-received, and increased perceived knowledge and competence. HDRC and similar courses may increase the quantity, quality and scope of HDR and thus move us closer to health equity.

Resident learning across the full range of core competencies through a transitions of care curriculum.

The authors developed a Transitions of Care (TOC) curriculum to teach and measure learner competence in performing TOC tasks for older adults. Internal medicine interns at an academic residency program received the curriculum, which consisted of experiential learning, self-study, and small group discussion. Interns completed retrospective pre/post surveys rating their confidence in performing five TOC tasks, qualitative open-ended survey questions, and a self-reflection essay. A subset of interns also completed follow-up assessments. For all five TOC tasks, the interns' confidence improved following completion of the TOC curriculum. Self-confidence persisted for up to 3 months later for some but not all tasks. According to the qualitative responses, the TOC curriculum provided interns with learning experiences and skills integral to performing safe care transitions. The TOC curriculum and a mixed-method assessment approach effectively teaches and measures learner competency in TOC across all six Accreditation Council for Graduate Medical Education competency domains.

Advancing Geriatrics Education Through a Faculty Development Program for Geriatrics-Oriented Clinician Educators.

Geriatrician and nongeriatrician faculty need instruction as teachers to provide quality training for a broader community of physicians who can care for the expanding population of older adults. Educators at Duke University designed a program to equip geriatrician and nongeriatrician faculty to develop quality educational programs and teach medical learners about geriatrics. Eighty-three faculty representing 52 institutions from across the United States participated in mini-fellowship programs (2005-09) consisting of workshops and 1-year follow-up mentoring by Duke faculty. Participants attended 1-week on-campus sessions on curriculum development and teaching skills and designed and implemented a curriculum in their home institution. Participant specialties included general medicine (nearly 50%), family medicine, surgery, psychiatry, rehabilitation medicine, and emergency medicine. Pre- and postprogram self-efficacy surveys, program evaluation surveys, and 6- and 12-month progress reports on scholars' educational projects were used to assess the effect of the Duke mini-fellowship programs on participants' educational practices. Forty-four scholars (56%) completed the end-of-year self-efficacy survey and end-of-program evaluation. Self-efficacy results indicated significant gains (P < .001) in 12 items assessed at 1 week and 1 year. Scholars reported the largest average gains at 1 year in applying adult learning principles in the design of educational programs (1.72), writing measurable learning objectives (1.51), and identifying optimal instructional methods to deliver learning objectives (1.50). Participants described improved knowledge and skills in designing curricula, implemented new and revised geriatrics curricula, and demonstrated commitment to faculty development and improving learning experiences for medical learners. This faculty development program improved participants' self-efficacy in curriculum design and teaching and enhanced geriatrics education in their home institutions.

Using the jigsaw cooperative learning method to teach medical students about long-term and postacute care.

Since many of the frailest and most vulnerable Americans reside in nursing homes, medical students need focused education and training pertaining to this setting. A unique cooperative learning experience utilizing the jigsaw method was developed to engage and expose students to the institutional long-term and postacute care (LTPAC) setting and the roles of personnel there. To accomplish these goals, small groups of medical students interviewed LTPAC personnel about their role, generally, and in relation to a specific patient case. These groups were then rearranged into new groups containing 1 student from each of the original groups plus a faculty facilitator. Each student in the new groups taught about the role of the LTPAC professional they interviewed. To assess the effectiveness of this learning experience, students and LTPAC personnel provided written feedback and rated the activity using a 5-point Likert scale (1 = worst; 5 = best). Students also took a knowledge test. The activity received ratings from students of 3.65 to 4.12 (mean = 3.91). The knowledge test results indicated that students understood the roles of the LTPAC personnel. In general, the jigsaw exercise was well-received by participants and provided an effective means of introducing medical students to the nursing home environment.

Connecting the learners: improving uptake of a nursing home educational program by focusing on staff interactions.

PURPOSE OF THE STUDY: The CONNECT intervention is designed to improve staff connections, communication, and use of multiple perspectives for problem solving. This analysis compared staff descriptions of the learning climate, use of social constructivist learning processes, and outcomes in nursing facilities receiving CONNECT with facilities receiving a falls education program alone. DESIGN AND METHODS: Qualitative evaluation of a randomized controlled trial was done using a focus group design. Facilities (n = 8) were randomized to a falls education program alone (control) or CONNECT followed by FALLS (intervention). A total of 77 staff participated in 16 focus groups using a structured interview protocol. Transcripts were analyzed using framework analysis, and summaries for each domain were compared between intervention and control facilities. RESULTS: Notable differences in descriptions of the learning climate included greater learner empowerment, appreciation of the role of all disciplines, and seeking diverse viewpoints in the intervention group. Greater use of social constructivist learning processes was evidenced by the intervention group as they described greater identification of communication weaknesses, improvement in communication frequency and quality, and use of sense-making by seeking out multiple perspectives to better understand and act on information. Intervention group participants reported outcomes including more creative fall prevention plans, a more respectful work environment, and improved relationships with coworkers. No substantial difference between groups was identified in safety culture, shared responsibility, and self-reported knowledge about falls. IMPLICATIONS: CONNECT appears to enhance the use of social constructivist learning processes among nursing home staff. The impact of CONNECT on clinical outcomes requires further study.

Design and evaluation of a prelicensure interprofessional course on improving care transitions.

Effective management of care transitions for older adults require the coordinated expertise of an interprofessional team. Unfortunately, different health care professions are rarely educated together or trained in teamwork skills. To address this issue, a team of professionally diverse faculty from the Duke University Geriatric Education Center designed an interprofessional course focused on improving transitions of care for older adults. This innovative prelicensure course provided interactive teaching sessions designed to promote critical thinking and foster effective communication among health care professionals, caregivers, and patients. Students were assessed by in-class and online participation, performance on individual assignments, and team-based proposals to improve care transitions for older patients with congestive heart failure. Twenty students representing six professions completed the course; 18 completed all self-efficacy and course evaluation surveys. Students rated their self-efficacy in several domains before and after the course and reported gains in teamwork skills (p < .001), transitions of care (p < .001), quality improvement (p < .001) and cultural competence (p < .001). Learner feedback emphasized the importance of enthusiastic and well-prepared faculty, interactive learning experiences, and engagement in relevant work. This course offers a promising approach to shifting the paradigm of health professions education to empower graduates to promote quality improvement through team-based care.

A framework for revising preservice curriculum for nonphysician clinicians: The mozambique experience.

Mozambique, with approximately 0.4 physicians and 4.1 nurses per 10,000 people, has one of the lowest ratios of health care providers to population in the world. To rapidly scale up health care coverage, the Mozambique Ministry of Health has pushed for greater investment in training nonphysician clinicians, Tιcnicos de Medicina (TM). Based on identified gaps in TM clinical performance, the Ministry of Health requested technical assistance from the International Training and Education Center for Health (I-TECH) to revise the two-and-a-half-year preservice curriculum. A six-step process was used to revise the curriculum: (i) Conducting a task analysis, (ii) defining a new curriculum approach and selecting an integrated model of subject and competency-based education, (iii) revising and restructuring the 30-month course schedule to emphasize clinical skills, (iv) developing a detailed syllabus for each course, (v) developing content for each lesson, and (vi) evaluating implementation and integrating feedback for ongoing improvement. In May 2010, the Mozambique Minister of Health approved the revised curriculum, which is currently being implemented in 10 training institutions around the country. Key lessons learned: (i) Detailed assessment of training institutions' strengths and weaknesses should inform curriculum revision. (ii) Establishing a Technical Working Group with respected and motivated clinicians is key to promoting local buy-in and ownership. (iii) Providing ready-to-use didactic material helps to address some challenges commonly found in resource-limited settings. (iv) Comprehensive curriculum revision is an important first step toward improving the quality of training provided to health care providers in developing countries. Other aspects of implementation at training institutions and health care facilities must also be addressed to ensure that providers are adequately trained and equipped to provide quality health care services. This approach to curriculum revision and implementation teaches several key lessons, which may be applicable to preservice training programs in other less developed countries.

CONNECT for better fall prevention in nursing homes: results from a pilot intervention study.

OBJECTIVES: To determine whether an intervention that improves nursing home (NH) staff connections, communication, and problem solving (CONNECT) would improve implementation of a falls reduction education program (FALLS). DESIGN: Cluster randomized trial. SETTING: Community (n=4) and Veterans Affairs (VA) NHs (n=4). PARTICIPANTS: Staff in any role with resident contact (n=497). INTERVENTION: NHs received FALLS alone (control) or CONNECT followed by FALLS (intervention), each delivered over 3 months. CONNECT used storytelling, relationship mapping, mentoring, self-monitoring, and feedback to help staff identify communication gaps and practice interaction strategies. FALLS included group training, modules, teleconferences, academic detailing, and audit and feedback. MEASUREMENTS: NH staff completed surveys about interactions at baseline, 3 months (immediately after CONNECT or control period), and 6 months (immediately after FALLS). A random sample of resident charts was abstracted for fall risk reduction documentation (n=651). Change in facility fall rates was an exploratory outcome. Focus groups were conducted to explore changes in organizational learning. RESULTS: Significant improvements in staff perceptions of communication quality, participation in decision-making, safety climate, caregiving quality, and use of local interaction strategies were observed in intervention community NHs (treatment-by-time effect P=.01) but not in VA NHs, where a ceiling effect was observed. Fall risk reduction documentation did not change significantly, and the direction of change in individual facilities did not relate to observed direction of change in fall rates. Fall rates did not change in control facilities (falls/bed per year: baseline, 2.61; after intervention, 2.64) but decreased by 12% in intervention facilities (falls/bed per year: baseline, 2.34; after intervention, 2.06); the effect of treatment on rate of change was 0.81 (95% confidence interval=0.55-1.20). CONCLUSION: CONNECT has the potential to improve care delivery in NHs, but the trend toward improving fall rates requires confirmation in a larger ongoing study.

An advanced course in long term care for geriatric medicine fellows.

Long term care deserves focused attention within a geriatric medicine fellowship curriculum to ensure that graduates are prepared not only for clinical care but also for the leadership, administrative, educational, quality improvement, and health policy aspects of their future roles. This report describes the curriculum development and program evaluation of an advanced course in long term care for geriatric medicine fellows and other graduate/post-graduate health professionals at Duke University. Course evaluation had 4 goals: (1) to determine how well the learning objectives were met; (2) to evaluate individual components of the course to improve subsequent offerings; (3) to determine whether additional topics needed to be added; and (4) to evaluate the effectiveness of the discussion forum component of the course. Learner self-efficacy improved within all competency areas but especially those of practice-based learning and system-based practice. Evaluation results led to curriculum revision that has maintained course relevance and sustained it within the larger geriatrics fellowship curriculum. Components of this course can be easily adapted to other curricular settings for fellows and residents.

Designing a learner-centered geriatrics curriculum for multilevel medical learners.

This article describes the development of a learner-centered, needs-based geriatrics curriculum for medical trainees, specifically, a geriatric block rotation for family medicine and internal medicine residents with the incorporation of a new group of learners: medical students. The objectives were to develop a curriculum that meets the needs of learners with diverse levels of geriatric experience and learning needs. The process used to accomplish these objectives is outlined. In an effort to design a learner-centered, competence-based curriculum, two instruments were developed. These instruments served to identify the learning needs of the varied levels of learners and to develop the specific goals and objectives of this 4-week geriatric rotation. The Geriatric Self-Competency Checklist (GSCC) and a Geriatric Knowledge Test were administered before and after the rotation. On average, learners identified eight priority learning needs using the GSCC. Evaluation and feedback from faculty and preceptors was also important in the identification of learning needs and during the learning process. Faculty development was initiated, focusing on the identification of competence in specific curricular areas. Examples of application of adult learning principles in curriculum design and implementation are also shared. No additional costs or faculty were required for this project, which is important if scarce academic geriatrics resources are to be used to reach the many more medical students and residents. This is essential for quality care needs of the rapidly aging population.