Assessment of an observed clinical skills exam in undergraduate medical education: a patient with opioid use disorder and chronic pain.

It is crucial that future physicians understand the nature of opioid use disorder (OUD). We designed a pilot Observed Structured Clinical Examination (OSCE) using simulated patients (SPs) experiencing OUD with concurrent chronic pain. The case was piloted in 2021 and 2022 during the multi-station OSCE that all the medical school clerkship students take at the end of their third year of medical school. A total of 111 medical students completed the OSCE in 2021 and 93 in 2022. The authors developed a case description and an assessment instrument for the SP to evaluate the student's performance on history taking, communication and professionalism. The evaluation was mixed-methods using SP evaluation data and a qualitative assessment of medical students' answers to 4 questions which were analyzed with a priori codes. In both years, the total scores for the case were slightly slower than the established OSCE cases in both years. A total of 75% (148/197) of students who responded to the assessment found the case difficult to manage. Strengths of the case included a majority of the students reporting the case helped them to identify strengths and weakness in assessing and treating OUD. Weaknesses included the lack of enough patient history and the perception that the SP was unrealistic (too nice). This pilot OSCE was challenging for the third year medical students based on the evaluative data. Given the scope of OUD and deaths, training students to identify and treat OUD during undergraduate medical education is of paramount importance.

A Mixed-Methods Program Evaluation of a Self-directed Learning Panel Management Curriculum in an Internal Medicine Residency Clinic.

BACKGROUND: Panel management (PM) curricula in internal medicine (IM) residency programs often assign performance measures which may not address the varied interests or needs of resident-learners. AIM: To evaluate a self-directed learning (SDL)-based PM curriculum. SETTING: University-based primary care practice in Burlington, Vermont. PARTICIPANTS: Thirty-five internal medicine residents participated. PROGRAM DESCRIPTION: Residents completed a PM curriculum that integrated SDL, electronic health record (EHR)-driven performance feedback, mentorship, and autonomy to set learning and patient care goals. PROGRAM EVALUATION: Pre/post-curricular surveys assessed EHR tool acceptability, weekly curricular surveys and post-curricular focus groups assessed resident perceptions and goals, and an interrupted time series analysis of care gap closure rates was used to compare the pre-intervention and intervention periods. Majority of residents (28-32 or 80-91%) completed the surveys and focus groups. Residents found the EHR tools acceptable and valued protected time, mentorship, and autonomy to set goals. A total of 13,313 patient visits were analyzed. There were no significant differences between rates between the pre-intervention period and the first intervention period (p=0.44). DISCUSSION: A longitudinal PM curriculum that incorporated SDL and goal setting with EHR-driven performance feedback was well-received by residents, however did not significantly impact the rate of care gap closure.

Perspectives of internal medicine residency clinics: A national survey of US medical directors.

Background: Ambulatory training is an integral component of internal medicine residency programs, yet details regarding operational processes in resident continuity clinics remain limited. Methods: We surveyed a convenience sample of medical directors of residency practices between 2015 and 2019 (n = 222) to describe and share operational and scheduling processes in internal medicine resident continuity clinics in the US. Results: Among residency practices, support for the medical director role ranged substantially, but was most commonly reported at 11%-20% full-time-equivalent support. By the end of the survey period, the majority of programs (65.1%) reported obtaining patient-centered medical home (PCMH) certification (level 1-3). For new patient appointments, 34.9% of programs reported a 1-7 day wait and 25.8% reported an 8-14 day wait. Wait times for new appointments were generally shorter for PCMH certified practices (P = 0.029). No-show rates were most commonly 26%-50% for new patients and 11%-25% for established patients. Most programs reported that interns see 3-4 patients per ½-day and senior residents see 5-6 patients per ½-day. Most interns and residents maintain a panel size of 51-120 patients. Discussion: Creating high-performing residency clinics requires a focus on core building blocks and operational processes. Based on the survey results and consensus opinion, we provide five summary recommendations related to (1) support for the medical director leadership role, (2) patient-centered and coordinated models of care, (3) support for patient scheduling, (4) recommended visit lengths, and (5) ancillary support, such as social work.

A Descriptive analysis of urine drug screen results in patients with opioid use disorder managed in a primary care setting.

BACKGROUND: Urine drug screening (UDS) is commonly used as part of treatment for opioid use disorder (OUD), including treatment with buprenorphine-naloxone for OUD in a primary care setting. Very little is known about the value of UDS, the optimum screening frequency in general, or its specific use for buprenorphine treatment in primary care. To address this question, we thought that in a stable population receiving buprenorphine-naloxone in the primary care setting it would be useful to know how often UDS yielded expected and unexpected results. METHODS: We present a descriptive analysis of UDS results in patients treated with buprenorphine-naloxone for OUD in a primary care setting over a two-year period. An unexpected test result is: 1. A negative test for buprenorphine and/or 2. A positive test for opioids, methadone, cocaine and/or heroin. RESULTS: A total of 161 patients received care during the study period and a total of 2588 test results were analyzed from this population. We found that 64.4% of the patient population (n = 104 patients) demonstrated both treatment adherence (as measured by buprenorphine positive test results) and no apparent unexpected test findings, as defined by negative tests for opioids, methadone, cocaine and heroin. Of the 161 patients, 20 results were positive for opioids, 5 for methadone, 39 for heroin and 2 for cocaine. Analysis at the UDS level demonstrated that, of the 2588 test results, 38 (1.5%) results did not have buprenorphine. Of the 2588, 28 (1.1%) test results were positive for opioids, 8 (0.3%) were positive for methadone, 39 (1.5%) for cocaine and 2 (0.1%) for heroin. CONCLUSION: Given that the majority of patients in our study had expected urine results, it may be reasonable for less frequent urine testing in certain patients.

Integrating DATA 2000 waiver training into undergraduate medical education: The time is now.

Background: Medications for opioid use disorder (MOUD) significantly reduce morbidity and mortality from opioid use disorder (OUD). To prescribe MOUD, physicians must obtain a DEA waiver through requirements outlined in the Drug Addiction Treatment Act of 2000 (DATA 2000). We developed an Addiction Medicine curriculum that features DATA 2000 waiver training at the Robert Larner, MD College of Medicine (LCOM). Methods: All third-year medical students completed a virtual DATA 2000 waiver training at the commencement of clinical clerkships. We conducted a curriculum needs assessment followed by pre- and post-training surveys to evaluate MOUD pharmacology knowledge and best prescribing practices. Results: Of LCOM students surveyed, 77.6% reported interest in being waivered to prescribed MOUD for OUD treatment. Third-year medical students demonstrated increases in both MOUD Pharmacology Knowledge from 64.2% to 84.8% (chi-squared = 40.8; p < .001) and MOUD Best Prescribing Practices from 55.9% to 75.2% (chi-squared = 29.9; p < .001). Discussion: Surveys showed the majority of students felt waiver training was relevant to their future practice. An online DATA 2000 waiver training format effectively improved student knowledge of MOUD. Conclusion: This curriculum exposed medical students to DATA 2000 waiver training, MOUD pharmacology and best practices, and increased the number of future physicians eligible to treat OUD using MOUD.

Internal Medicine Resident Experiences With a 5-Month Ambulatory Panel Management Curriculum.

BACKGROUND: Panel management is emphasized as a subcompetency in internal medicine graduate medical education. Despite its importance, there are few published curricula on population medicine in internal medicine residency programs. OBJECTIVE: We explored resident experiences and clinical outcomes of a 5-month diabetes and obesity ambulatory panel management curriculum. METHODS: From August through December 2016, internal medicine residents at the University of Vermont Medical Center reviewed registries of their patients with diabetes, prediabetes, and obesity; completed learning modules; coordinated patient outreach; and updated gaps in care. Resident worksheets, surveys, and reflections were analyzed using descriptive and thematic analyses. Before and after mean hemoglobin A1c results were obtained for patients in the diabetic group. RESULTS: Most residents completed the worksheet, survey, and reflection (93%-98%, N = 42). The worksheets showed 70% of participants in the diabetic group had appointments scheduled after outreach, 42% were offered referrals to the Community Health Team, and 69% had overdue laboratory tests ordered. Residents reported they worked well with staff (95%), were successful in coordinating outreach (67%), and increased their sense of patient care ownership (66%). In reflections, identified successes were improved patient care, teamwork, and relationship with patients, while barriers included difficulty ensuring follow-up, competing patient priorities, and difficulty with patient engagement. Precurricular mean hemoglobin A1c was 7.7%, and postcurricular was 7.6% (P = .41). CONCLUSIONS: The curriculum offered a feasible, longitudinal model to introduce residents to population health skills and interdisciplinary care coordination. Although mean hemoglobin A1c did not change, residents reported improved patient care. Identified barriers present opportunities for resident education in patient engagement.

Resident and Preceptor Perceptions of Preceptor Integration Into Resident Clinic Scheduling Templates.

BACKGROUND: Some internal medicine residency programs on X+Y schedules have modified clinic preceptor schedules to mimic those of the resident cohort (resident matched). This is in contrast to a traditional model, in which preceptors supervise on the same half-day each week. OBJECTIVE: We assessed preceptor and resident perceptions of the 2 precepting models. METHODS: We surveyed 44 preceptors and 97 residents at 3 clinic sites in 2 academic medical centers. Two clinics used the resident-matched model, and 1 used a traditional model. Surveys were completed at 6 months and 1 year. We assessed resident and preceptor perceptions in 5 domains: relationships between residents and preceptors; preceptor familiarity with complex patients; preceptor ability to assess milestone achievements; ability to follow up on results; and quality of care. RESULTS: There was no difference in perceptions of interpersonal relationships or satisfaction with patient care. Preceptors in the resident-matched schedule reported they were more familiar with complex patients at both 6 months and 1 year, and felt more comfortable evaluating residents' milestone achievements at 6 months, but not at 1 year. At 1 year, residents in the resident-matched model perceived preceptors were more familiar with complex patients than residents in the traditional model. The ability to discuss patient results between clinic weeks was low in both models. CONCLUSIONS: The resident-matched model increased resident and preceptor perceptions of familiarity with complex patients and early preceptor perceptions of comfort in assessment of milestone achievements.