Motivational interviewing skills practice enhanced with artificial intelligence: ReadMI.

BACKGROUND: Finding time in the medical curriculum to focus on motivational interviewing (MI) training is a challenge in many medical schools. We developed a software-based training tool, "Real-time Assessment of Dialogue in Motivational Interviewing" (ReadMI), that aims to advance the skill acquisition of medical students as they learn the MI approach. This human-artificial intelligence teaming may help reduce the cognitive load on a training facilitator. METHODS: During their Family Medicine clerkship, 125 third-year medical students were scheduled in pairs to participate in a 90-minute MI training session, with each student doing two role-plays as the physician. Intervention group students received both facilitator feedback and ReadMI metrics after their first role-play, while control group students received only facilitator feedback. RESULTS: While students in both conditions improved their MI approach from the first to the second role-play, those in the intervention condition used significantly more open-ended questions, fewer closed-ended questions, and had a higher ratio of open to closed questions. CONCLUSION: MI skills practice can be gained with a relatively small investment of student time, and artificial intelligence can be utilized both for the measurement of MI skill acquisition and as an instructional aid.

PRESTO: Promoting Engagement for the Safe Tapering of Opioids.

ABSTRACT: Twenty-four percent of all U.S. opioid overdose deaths involve a prescription opioid. Changing prescribing practices is considered a key step in reducing opioid overdoses. Primary care providers (PCPs) commonly lack the patient engagement skills needed to address patient resistance to taper or end opioid prescriptions. We developed and evaluated a protocol aimed at improving PCP opioid-prescribing patterns and modeled on the evidence-based Screening, Brief Intervention, and Referral to Treatment (SBIRT) approach. We conducted a time series trial comparing provider opioid prescribing 8 months before and 8 months after training with the PRomoting Engagement for Safe Tapering of Opioids (PRESTO) protocol. The 148 Ohio PCPs who completed PRESTO training gained confidence in their ability to engage their patients on the topics of opioid overdose risk and potential opioid tapering. Promoting Engagement for Safe Tapering of Opioids participants had decreased opioid-prescribing over time, but this was not significantly different from Ohio PCPs who had not received PRESTO training. Participants completing PRESTO training had small, but significant increased buprenorphine prescribing over time compared with Ohio PCPs who had not received PRESTO training. The PRESTO approach and opioid risk pyramid warrant further study and validation.

Forming Cardi-OH: A Statewide Collaborative to Improve Cardiovascular Health in Ohio.

Background Cardiovascular risk factor control is challenging, especially in disadvantaged populations. However, few statewide efforts exist to tackle this challenge. Therefore, our objective is to describe the formation of a unique statewide cardiovascular health collaborative so others may learn from this approach. Methodology With funding from the Ohio Department of Medicaid's Ohio Medicaid Technical Assistance and Policy Program, we used a collective impact model to link the seven medical schools in Ohio, primary care clinics across the state, the Ohio Department of Medicaid, and Ohio's Medicaid Managed Care Plans in a statewide health improvement collaborative for expanding primary care capacity to improve cardiovascular health in Ohio. Results Initial dissemination activities for primary care teams included a virtual case-based learning series focused on hypertension and social determinants of health, website resources, a monthly newsletter with clinical tips, webinars, and in-person conferences. The collaborative is aligned with a separately funded hypertension quality improvement project for paired implementation. Conclusions The collective impact model is a useful framework for developing a statewide collaborative focused on the dissemination and implementation of evidence-based best practices for cardiovascular health improvement and disparity reduction. Statewide collaboratives bringing payers, clinicians, and academic partners together have the potential to substantially impact cardiovascular health.

Turning "Lose-Lose" into "Win-Win": What Is Good for Them Is Good for Us!

Simply telling patients what to do with respect to medical recommendations or lifestyle changes often does not have the desired impact, contributing to frustration for both patients and physicians. Therefore, this "educate and advise" approach can be a "lose-lose" proposition-bad for the patient, and bad for the physician. Broader adoption of efficacious approaches to patient engagement, such as motivational interviewing, can help make the process of addressing patients' behavioral responsibilities regarding chronic disease prevention and management a "win-win" for the health and satisfaction of patients and physicians alike. Greater emphasis on evidence-based patient engagement skills is necessary in medical education.

Advancing Motivational Interviewing Training with Artificial Intelligence: ReadMI.

BACKGROUND: Motivational interviewing (MI) is an evidence-based, brief interventional approach that has been demonstrated to be highly effective in triggering change in high-risk lifestyle behaviors. MI tends to be underutilized in clinical settings, in part because of limited and ineffective training. To implement MI more widely, there is a critical need to improve the MI training process in a manner that can provide prompt and efficient feedback. Our team has developed and tested a training tool, Real-time Assessment of Dialogue in Motivational Interviewing (ReadMI), that uses natural language processing (NLP) to provide immediate MI metrics and thereby address the need for more effective MI training. METHODS: Metrics produced by the ReadMI tool from transcripts of 48 interviews conducted by medical residents with a simulated patient were examined to identify relationships between physician-speaking time and other MI metrics, including the number of open- and closed-ended questions. In addition, interrater reliability statistics were conducted to determine the accuracy of the ReadMI's analysis of physician responses. RESULTS: The more time the physician spent talking, the less likely the physician was engaging in MI-consistent interview behaviors (r = -0.403, p = 0.007), including open-ended questions, reflective statements, or use of a change ruler. CONCLUSION: ReadMI produces specific metrics that a trainer can share with a student, resident, or clinician for immediate feedback. Given the time constraints on targeted skill development in health professions training, ReadMI decreases the need to rely on subjective feedback and/or more time-consuming video review to illustrate important teaching points.

Promoting Motivational Interviewing in Primary Care: More Than Intention.

INTRODUCTION: Interacting with patients in a manner that furthers self-responsibility for health is an important skill for primary care clinicians. Motivational interviewing (MI) is such an approach to patient engagement, but it remains to be more widely implemented. In a program training health professionals and health professions students in MI, we examined posttraining attitudes and intentions regarding the utilization of MI. Of particular interest was how posttraining intentions were associated with self-reported action 1 month later. METHODS: We obtained immediate posttraining and 30-day follow-up data from 209 participants regarding intent to utilize the MI approach (self-reported implementation at the follow-up interval), impact on confidence with patient interaction, and perceived importance of the training. We analyzied frequencies and percentages for all categorical/ordinal variables to describe the participants and the survey question responses. RESULTS: While 91.5% of participants intended to incorporate MI into their approach with patients (to a moderate or great extent) at posttraining, only 48.7% reported that they had actually implemented the MI approach (to a moderate or great extent) 30 days later. However, another 32.1% indicated that they had occasionally utilized MI. Attitudes toward the importance of MI training and the impact of training on confidence remained strong over the 30 days. CONCLUSION: Achieving more widespread implementation of the MI approach in the primary care setting is likely to be less dependent on convincing clinicians about its importance for patient engagement, but rather on the translation of intent to actual practice and implementation.

Does this patient have jugular venous distension? Vein finder-enhanced assessment of jugular venous pressure.

Assessing jugular venous pressure (JVP) may be challenging yet useful for establishing the bedside diagnosis of congestive heart failure. Vein finder lights illuminate superficial veins and thus can improve visualization of the external jugular vein.

Flipped Exam Room.

Medical education has taken a decided turn toward the "flipped classroom," in which in-class lectures are de-emphasized and engaged learning is promoted. The time has also come to make some changes in what is being taught in clinical medicine, specifically with respect to the patient-physician interaction. Because the daily management of chronic illness is primarily the responsibility of the patient, clinical encounters that prioritize patient engagement and activation are critical. The traditional medical encounter, characterized by data gathering to make a diagnosis followed by prescribing or recommending treatment to the patient, can work well for acute illnesses or injuries, but effective chronic disease management requires substantial patient ownership of their health. In a "flipped exam room," interactions with patients emphasize patient responsibility for health, such that priority is given to eliciting patient goals, what the patient knows, and how they desire to proceed with management of their health concerns and conditions. Just as medical students find engaged learning approaches to be more acceptable and satisfying, patients find collaborative interaction approaches on the part of their physicians to be more satisfying, and such approaches are associated with better outcomes. More attention to training students and residents in "flipped exam room" patient interaction skills is necessary.

Stress Electrocardiography vs Radionuclide Myocardial Perfusion Imaging among Patients Admitted for Chest Pain: Comparison of Teaching and Nonteaching Hospital Services.

OBJECTIVES: The American Board of Internal Medicine Foundation's Choosing Wisely initiative has identified the routine use of stress cardiac imaging among lower-risk patients as an expensive test that should be questioned by both physicians and patients. The objectives of this study were to determine how often patients hospitalized for chest pain are assessed with stress electrocardiography (stress ECG) compared with radionuclide myocardial perfusion imaging (rMPI) and to evaluate whether the cardiac testing guidelines of the American Heart Association and the Choosing Wisely campaign are being followed. We also sought to determine whether there were differences in practice patterns between a teaching and a nonteaching hospital service. METHODS: We conducted a retrospective chart review of 842 consecutive patients admitted with the primary diagnosis of chest pain to a 900-bed university-affiliated teaching hospital in Dayton, Ohio. After exclusions, we analyzed records from 111 teaching service and 94 nonteaching service patients. We assessed whether patients were evaluated with stress ECG or rMPI and compared the teaching service with the nonteaching service. RESULTS: The nonteaching service obtained rMPI more often than the teaching service (94% vs 51%, P < 0.001) and stress ECG less frequently than the teaching service (1% vs 12%, P < 0.003). Both groups may have overused rMPI, choosing it over the less costly alternative of stress ECG testing 71% of the time. CONCLUSIONS: Adherence to the Choosing Wisely recommendations for the appropriate use of stress ECG is suboptimal among both teaching and nonteaching physicians. Choosing stress ECG, when appropriate, could translate into substantial cost savings and reduce potentially harmful radiation exposure.

Rhabdomyolysis in the setting of induced hypothyroidism and statin therapy: a case report.

Mild elevation of creatine kinase (CK) is common in untreated hypothyroidism, but severe myositis and overt rhabdomyolysis are rare. Similarly, muscle pain and CK elevation are potential side effects of statin therapy, yet rhabdomyolysis is likewise rare in the absence of medication interactions adversely affecting statin metabolism. The coexistence of statin therapy and hypothyroid states may synergistically increase the risk of myopathy. We describe a case of rhabdomyolysis attributable to induced hypothyroidism in a patient on chronic statin medication who was anticipating adjuvant radioiodine ((131)I) therapy for a thyroid carcinoma.

Effects of cocaine-positive urine screens on serum thyrotropin levels in patients admitted to an inpatient mental health unit.

OBJECTIVE: To assess the effect of a positive urine screen for cocaine on thyrotropin (TSH, also thyroid-stimulating hormone) concentrations. METHODS: In this retrospective cohort study, patients admitted to the mental health unit at an academic inpatient setting with a diagnosis of cocaine dependence or cocaine intoxication were routinely screened with urine drug toxicology tests and TSH concentrations. TSH concentrations from patients who tested positive for cocaine on urine toxicology were compared with patients having negative cocaine screenings. RESULTS: A total of 192 patients were included: 122 with a positive cocaine screen and 70 with a negative cocaine screen. All patients were screened using a highly sensitive TSH assay. A positive cocaine screen was not associated with a statistically significant difference in TSH concentrations compared with a negative cocaine screen. The percentage of patients with hypothyroidism (TSH >4.50 µIU/mL) or hyperthyroidism (TSH <0.40 µIU/mL) were similar in both study groups. CONCLUSIONS: The study failed to show that a positive urine screen for cocaine was associated with a significant effect on serum TSH levels in patients admitted to a mental health unit with a diagnosis of cocaine dependence or cocaine intoxication. Our findings support those of a prior study that cocaine use does not affect routine thyroid function tests. The present study does not support the clinical practice of ordering a serum TSH screening test on patients admitted to inpatient psychiatry units soley because the urine screen is positive for cocaine.

Discharge against medical advice: how often do we intervene?

BACKGROUND: Discharges against medical advice (AMA) occur in 1% to 2% of hospital stays and are associated with increased morbidity, readmission rates, and 30-day mortality. Risk factors associated with AMA have been investigated, but interventions at the time of discharge have not been carefully examined. METHODS: We retrospectively reviewed the records of adult patients discharged AMA over a 2-year period from the general medical service of a university-affiliated tertiary care hospital. We assessed for presence of documentation addressing informed consent, patient decision-making capacity, health literacy, follow-up plans, whether medications were prescribed, and whether any warning indicators of impending AMA were apparent. RESULTS: Two hundred ninety-one records were reviewed. AMA notes were present in 276 (94.8%) charts. Notes were authored by physicians in 163 (59.1%) and nurses in 110 (37.8%) encounters. Informed consent was present in 88 (30.2%) charts, mentioned in the note but not present in the chart in 111 (38.1%), and not signed in 92 (31.6%) charts. Decision-making capacity and health literacy were documented in 108 (37.1%) and 75 (25.8%) records, respectively. Warning of impending AMA was present in 217 (74.6%) charts. Medications prescribed and follow-up plans were documented in 71 (24.4%) and 91 (31.3%) charts, respectively. CONCLUSIONS: Advance warning of impending AMA is often present, yet only a minority of cases have prescription of medications or development of follow-up plans. Medical documentation of AMA dispositions is frequently inadequate, suggesting missed opportunities to intervene as well as suboptimal medicolegal scenarios.

Night float teaching and learning: perceptions of residents and faculty.

BACKGROUND: Most internal medicine residency programs use a night float system to comply with resident duty hour limits. Night float assignments often comprise 7 to 10 weeks of scheduled clinical time during training. Despite this substantial allotment of time to night float, few studies have assessed the adequacy of learning opportunities during these rotations. We designed an exploratory study to assess resident and faculty views about the educational aspects of a typical internal medicine night float system. METHODS: Wright State University Boonshoft School of Medicine internal medicine residents and attending faculty were asked to complete a 25-item voluntary, anonymous survey. A 5-point Likert scale was used to assess perceptions of education during day and night rotations. RESULTS: The response rate was 52% (85 of 164). Residents rated teaching and learning on day rotations more positively than on night rotations for 17 of 25 (68%) items. Regarding night float, residents rated 14 of 25 items below 3.00; only one item was rated below 3.00 ("…H & P skills observed by attending") for day rotations. Attending physicians rated day rotations more highly for all 25 survey items. Faculty rated 13 of 25 items below 3.00 for night float and they rated no items below 3.00 for day rotations. Resident and faculty ratings differed significantly for 10 items, with 5 items receiving higher ratings by residents and 5 being rated more positively by faculty. CONCLUSION: Despite a substantial allotment of time to night rotations, there appear to be lost teaching and learning opportunities in the current night float system. Modification of the existing format may improve its educational value.