Use of Telehealth for Opioid Use Disorder Treatment in Safety Net Primary Care Settings: A Mixed-Methods Study.

Background: The COVID-19 pandemic resulted in a marked increase in telehealth for the provision of primary care-based opioid use disorder (OUD) treatment. This mixed methods study examines characteristics associated with having the majority of OUD-related visits via telehealth versus in-person, and changes in mode of delivery (in-person, telephone, video) over time. Methods: Logistic regression was performed using electronic health record data from patients with ≥1 visit with an OUD diagnosis to ≥1 of the two study clinics (Rural Health Clinic; urban Federally Qualified Health Center) and ≥1 OUD medication ordered from 3/8/2020-9/1/2021, with >50% of OUD visits via telehealth (vs. >50% in-person) as the dependent variable and patient characteristics as independent variables. Changes in visit type over time were also examined. Inductive coding was used to analyze data from interviews with clinical team members (n = 10) who provide OUD care to understand decision-making around visit type. Results: New patients (vs. returning; OR = 0.47;95%CI:0.27-0.83), those with ≥1 psychiatric diagnosis (vs. none; OR = 0.49,95%CI:0.29-0.82), and rural clinic patients (vs. urban; OR = 0.05; 95%CI:0.03-0.08) had lower odds of having the majority of visits via telehealth than in-person. Patterns of visit type varied over time by clinic, with the majority of telehealth visits delivered via telephone. Team members described flexibility for patients as a key telehealth benefit, but described in-person visits as more conducive to building rapport with new patients and those with increased psychological burden. Conclusion: Understanding how and why telehealth is used for OUD treatment is critical for ensuring access to care and informing OUD-related policy decisions.

Improving Management of Opioid Use Disorder Training With Novel Resident Co-PCP Model.

Introduction: Multiple organizations have recommended primary care physicians (PCP) implement medication for opioid use disorder (MOUD) programs to address the opioid epidemic, but that has been hindered by residency graduates feeling unprepared to provide these services. This study describes a program innovation to increase exposure to MOUD in residents' own continuity practices. Methods: We designed, reviewed, and implemented a co-PCP model to increase resident MOUD visits at one rural health clinic in the Pacific Northwest that is part of a large academic health center. We then measured resident MOUD panels before and after to assess success of this novel program. Results: After implementation of the novel co-PCP model, the number of residents having at least three MOUD patients increased from two (25%) to eight (100%) over 8 months. Conclusions: The novel co-PCP model of care effectively increased exposure to MOUD care in one resident continuity practice. This may be a successful practice change for improving resident preparation to provide MOUD care after graduation and to expand access to these services for further progress on the opioid epidemic.

An Effective Gender-Affirming Care and Hormone Prescribing Standardized Patient Case for Residents.

Introduction: It is estimated that at least 700,000 individuals in the United States identify as transgender or gender expansive. Many have confronted marginalization within the health care system, leading to suboptimal care and inequitable health outcomes. Health sciences trainees do not receive adequate training in gender-affirming care. The authors therefore created, piloted, and evaluated a formative standardized patient case for gender-affirming care for family medicine resident learners that could be given with limited resources in primary care and health professional education. Methods: The curriculum for the case was developed with patient input and with family medicine physicians skilled in education, simulation, and gender-affirming care. The first case was held for 20 residents in a 4-year family medicine program in the Pacific Northwest. Nineteen participants completed pre/post case surveys delineating knowledge, awareness, attitudes, and intended behavior regarding providing gender-affirming care. Results: Self-reported knowledge and awareness increased after standardized patient case participation in multiple skill areas related to providing gender-affirming care. Faculty observers informally reported that the session increased their knowledge and comfort as well. Discussion: Implementation of this gender-affirming standardized patient case inclusive of community input was associated with successful improvements in self-reported measurements of resident knowledge and awareness of providing gender-affirming care. Additional institutions should consider such training to improve health care equity for this population.

"What Questions Do You Have?": Teaching Medical Students to Use an Open-Ended Phrase for Eliciting Patients' Questions.

Patients frequently do not understand health information received in clinical settings, yet rates of question-asking by patients are low, particularly for patients with lower health literacy skills. Experts recommend that health care professionals attempt to elicit patients' questions by using an open-ended phrase, such as "What questions do you have?" as opposed to a closed-ended phrase like, "Do you have any questions?" We compared question-eliciting techniques used during video-recorded observed structured clinical examinations among medical students who had completed a mostly didactic curriculum on health literacy and clear communication (n = 46) to students who completed a newer longitudinal problem-based communication curriculum (n = 32). Students were not aware that they were being observed for specific communication skills. Compared to controls, students in the intervention group were more likely to spontaneously attempt to elicit questions from a standardized patient (65.2% vs. 84.4%, p = .06), and were significantly more likely to use an open-ended phrase to do so (6.7% vs. 51.9%, p = .0002). The longitudinal communication skills curriculum was successful in creating long-term patient-centered question-eliciting habits. Further research is needed to determine whether eliciting questions with an open-ended technique result in patients asking more or different clarifying questions during the closing phase of clinical encounters. [HLRP: Health Literacy Research and Practice. 2022;6(1):e12-e16.].

Tier-based treatment for opioid use disorder in the primary care setting.

Background: Two primary care clinics implemented an opioid use disorder (OUD) treatment program that integrates behavioral health counseling with buprenorphine treatment and uses tiers. This project aimed to understand how patients moved through tiers in this program. Method: We purposively sampled 20 patients with at least 10 OUD-related treatment visits; we documented tier changes at all visits between September 1, 2016 and December 31, 2018 using a standard data collection instrument. These data were used to construct run-charts. Results: About 45% of sampled patients had at least one relapse noted and 60% of patients dropped in tier during the study. Reductions in tier often happened when the patient was navigating difficult psychosocial situations in their life, whereas increases in tier often accompanied positive life events. We also found variation in use of the tiers. Discussion: OUD treatment from two clinics by tier illustrates that recovery is an individualized process based on patient need that can fluctuate due to psychosocial triggers and significant life events. Having tiers can guide treatment and provide both clinicians and patients with information about what to expect during treatment while still allowing the flexibility to meet patients where they are. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Associations of retention on buprenorphine for opioid use disorder with patient characteristics and models of care in the primary care setting.

INTRODUCTION: Buprenorphine, a medication for opioid use disorder (OUD), can be administered within primary care; however, little is known about characteristics associated with retention on buprenorphine in these settings. This study examines patient correlates of buprenorphine retention and whether an integrated, interdisciplinary treatment model (buprenorphine and behavioral health) is associated with higher odds of buprenorphine retention than a primarily medication-only treatment model. METHODS: Electronic health record data from adult patients with an OUD, ≥1 buprenorphine order and ≥1 visit to either of two primary care clinics between 9/2/2014-6/27/2018 were extracted (N = 494 patients). Two research team members reviewed the medication start and stop dates for each buprenorphine order and classified as retained (≥6 months of orders) or not retained (<6 months of orders). Logistic regressions estimated the odds of retention on buprenorphine by 1) patient characteristics and 2) timing of patient's engagement in buprenorphine treatment (pre- or post-implementation of an integrated treatment model). RESULTS: Of the study sample, 53% had ≥6 months of buprenorphine orders. Almost two times higher odds of retention were found among patients with ≥1 psychiatric comorbidity (versus none) and among those with buprenorphine orders in the post- versus pre-period. CONCLUSIONS: An integrated, interdisciplinary model of OUD treatment was associated with ≥6 months of buprenorphine orders among our study population. Continued research is needed in real-world primary care settings to understand the impact of OUD treatment models on patient outcomes. A more nuanced examination of the associations between psychiatric diagnoses and buprenorphine treatment retention is warranted.

Assessing Physician Assistant Student Electronic Health Record Competency Using an Objective Structured Clinical Examination.

PURPOSE: Evaluate didactic year physician assistant (PA) student competency in electronic health record (EHR) communication and data management. METHODS: This study used an Objective Structured Clinical Examination (OSCE) to measure PA students' EHR patient communication and data skills. RESULTS: Most students demonstrated good EHR communication skills overall, while few students moved the computer to better facilitate the visit or verified the patient's identity. Additionally, few students demonstrated EHR data skills by reviewing patient history and medications. CONCLUSIONS: Utilizing an OSCE to assess EHR competence can highlight areas for curricular improvement in order to improve EHR skills.

Effects of Implementing an Interactive Substance Use Disorders Workshop on a Family Medicine Clerkship.

BACKGROUND AND OBJECTIVES: Substance use disorders (SUD) remain a public health crisis and training has been insufficient to provide the skills necessary to combat this crisis. We aimed to create and study an interactive, destigmatizing, skills-based workshop for medical students to evaluate if this changes students' self-reported knowledge, skills, and attitudes toward patients with SUD. METHODS: We surveyed students on a required family medicine outpatient rotation at a Pacific Northwest medical school during clerkship orientation on their views regarding SUDs utilizing the validated Drug and Drug Problems Perceptions Questionnaire containing a 7-point Likert scale. After attending a substance use disorder workshop, they repeated the survey. We calculated differences between the paired pre- to postsurveys. RESULTS: We collected the pre- and postdata for 118 students who attended the workshop and showed statistically significant positive differences on all items. CONCLUSIONS: The positive change in the medical students' reported attitudes suggests both necessity and feasibility in teaching SUD skills in a destigmatizing way in medical training. Positive changes also suggest a role of exposing students to family medicine and/or primary care as a strategy to learn competent care for patients with substance use disorders.

Peripheral Neuropathy: Evaluation and Differential Diagnosis.

Peripheral neuropathy, a common neurologic problem encountered by family physicians, can be classified clinically by the anatomic pattern of presenting symptoms and, if indicated, by results of electrodiagnostic studies for axonal and demyelinating disease. The prevalence of peripheral neuropathy in the general population ranges from 1% to 7%, with higher rates among those older than 50 years. Common identifiable causes include diabetes mellitus, nerve compression or injury, alcohol use, toxin exposure, hereditary diseases, and nutritional deficiencies. Peripheral neuropathy is idiopathic in 25% to 46% of cases. Diagnosis requires a comprehensive history, physical examination, and judicious laboratory testing. Early peripheral neuropathy may present as sensory alterations that are often progressive, including sensory loss, numbness, pain, or burning sensations in a "stocking and glove" distribution of the extremities. Later stages may involve proximal numbness, distal weakness, or atrophy. Physical examination should include a comprehensive neurologic and musculoskeletal evaluation. If the peripheral nervous system is identified as the likely source of the patient's symptoms, evaluation for potential underlying etiologies should initially focus on treatable causes. Initial laboratory evaluation includes a complete blood count; a comprehensive metabolic profile; fasting blood glucose, vitamin B12, and thyroid-stimulating hormone levels; and serum protein electrophoresis with immunofixation. If the initial evaluation is inconclusive, referral to a neurologist for additional testing (e.g., electrodiagnostic studies, specific antibody assays, nerve biopsy) should be considered. Treatment of peripheral neuropathy focuses on managing the underlying etiology. Several classes of medications, including gabapentinoids and antidepressants, can help alleviate neuropathic pain.

Predictors of Medication-Assisted Treatment Initiation for Opioid Use Disorder in an Interdisciplinary Primary Care Model.

INTRODUCTION: Medication-assisted treatment (MAT) for opioid use disorder (OUD) is underused in primary care. Little is known about patient demographics associated with MAT initiation, particularly among models with an interdisciplinary approach, including behavioral health integration. We hypothesize few disparities in MAT initiation by patient characteristics after implementing this model for OUD. METHODS: Electronic health record data were used to identify adults with ≥1 primary care visit in 1 of 2 study clinics in a Pacific Northwest academic health system between September 1, 2015 and August 31, 2017 (n = 23,372). Rates of documented OUD diagnosis were calculated. Multivariate logistic regression estimated odds ratios of MAT initiation, defined as ≥1 electronic health record order for buprenorphine or naltrexone, by patient covariates. RESULTS: Seven percent of the study sample had an OUD diagnosis. Of those patients, 32% had ≥1 MAT order. Patients with documented psychiatric diagnoses or tobacco use had higher odds of initiating MAT (odds ratio [OR] = 1.62, P = .0003; OR = 2.46, P < .0001, respectively). Uninsured, Medicaid, and Medicare patients had lower odds than those commercially insured (OR = 0.53, 0.38, and 0.31, respectively; P < .0001). Patients who were older, of a race/ethnicity other than non-Hispanic white, had documented diabetes, and had documented asthma or chronic obstructive pulmonary disease showed lower odds of initiation. DISCUSSION: MAT initiation varied by patient characteristics, including disparities by insurance coverage and race/ethnicity. The addition of behavioral health did not eliminate disparities in care, but higher odds of initiation among those with a documented psychiatric diagnosis may suggest this model reaches some vulnerable populations. Additional research is needed to further examine these findings.

Design and Implementation of a Competency-Based Family Medicine Clerkship Curriculum.

BACKGROUND AND OBJECTIVES: Competency-based medical education (CBME) has been incorporated into graduate medical education accreditation and is being introduced in undergraduate medical education. Family medicine (FM) faculty at one institution developed a CBME FM clerkship to intentionally maintain the integrity of FM specialty-specific teaching during their institutional CBME curricular revision. METHODS: From the five FM domains (Access to Care, Continuity of Care, Comprehensive Care, Coordination of Care, and Contextual Care), 10 competencies and 23 FM educational activities (EAs) were defined. The set of EAs encompasses the wide scope of care available to FM clerkship students. Students complete four required EAs (preventive care, care transitions, chronic disease management, and acute care) and select four additional EAs matching their interests. EA selection frequency and course evaluations were assessed for the first cohort of learners (N=156; February 2016-July 2017). RESULTS: The most frequently selected EAs were: information coordination, procedures, and care of the family. The least selected were: patient e-communication, end-of-life care, and shared medical decision making. Student perceptions of the experience were strong prior to and after implementation. CONCLUSIONS: Having both required and selective EAs ensures a robust FM experience tailored to students' interests. The FM CBME curriculum allowed comparable clinical experiences despite variations in clinical sites and preceptor scope. Because of its breadth, FM is uniquely suited to address multiple competencies; this demonstrates the educational value of required FM clerkships to institutional leaders interested in implementing CBME curriculum. The CBME framework can provide a structure for more intentional student-clinic assignments based on EAs available at specific sites.

Insomnia Telemedicine OSCE (TeleOSCE): A Simulated Standardized Patient Video-Visit Case for Clerkship Students.

Introduction: Telemedicine is a growing practice with minimal training in US medical schools. Telemedicine OSCE (TeleOSCE) simulations allow students to practice this type of patient interaction in a standardized way. Methods: The Insomnia-Rural TeleOSCE was implemented as part of a required clinical clerkship for students in their second, third, or fourth year of medical school. This case addressed a patient with depression in a medically underserved area. Students performed it as a formative experience and received immediate feedback. They then completed a survey to evaluate the experience. Results: Students (n = 287) rated the quality of the experience 7.59 out of 10. Comments showed that 61 learners thought the TeleOSCE was a positive experience, 35 wanted more teaching about telemedicine, 28 improved their understanding of barriers to care, 25 expressed concern over minimal other training, 23 found the TeleOSCE important and challenging, 16 appreciated the differences between in-person and remote visits, and 15 wanted fewer distractions. Eight students worried about how they would be judged, five learned from the technical limitations, five requested more time, five were skeptical of the utility, and five saw telemedicine as triage. Discussion: The TeleOSCE allows learners to gain exposure to telemedicine in a safe simulated teaching environment and assesses learner competencies. The TeleOSCE also improves students' understanding of barriers to care and the utility of telemedicine. It logistically allows faculty to directly assess distance students on their clinical reasoning and patient communication skills.

Validation and Comparison of a Brief Instrument vs a Single-Item Screen to Predict Entry to Family Medicine at Matriculation to Medical School.

BACKGROUND AND OBJECTIVES: A strong US primary care workforce is necessary to meet health care needs, yet fewer than 9% of allopathic medical students choose family medicine each year. No validated instrument exists to identify students likely to enter family medicine upon medical school matriculation. METHODS: A subset of a larger survey at the University of Washington School of Medicine (UWSOM) was used to create the Family Medicine Interest Survey (FMIS), a 15-item instrument to predict eventual practice in family medicine for a 2003-2007 matriculating cohort. A single-item screen asking about top specialty choice was administered at UWSOM for the same cohort and for a 2006-2012 matriculating cohort of students at Oregon Health & Science University (OHSU). Test performance measures including D (discrimination) and Cronbach α were calculated. Logistic regression determined whether FMIS score or reporting family medicine as the top specialty choice predicted family medicine practice for 601 UWSOM graduates or family medicine residency match for 744 OHSU graduates. RESULTS: The FMIS is reliable (Cronbach α=0.76). Both tests significantly predicted the probability of entering family medicine. Listing family medicine as the preferred specialty choice yielded a 47% predicted probability for UWSOM graduates entering family medicine. OHSU graduates listing family medicine first had an eightfold odds of matching to family medicine residencies. Combining the two instruments for UWSOM graduates showed a dose-response curve for predicted probability of entering family medicine with increasing levels of interest. CONCLUSION: Each screening tool can predict students more likely to enter family medicine upon matriculation.

Specialty Choice Stability: Are There Implications for Early Entry Into Residency?

INTRODUCTION: The medical education community is piloting early entry to residency as a potential outcome to competency-based education and as a way to more quickly train future physicians in specialties of need. However, there is limited knowledge of which specialties may be best suited to this streamlined training. Student career desires may change over the course of their undergraduate training. We aimed to understand which specialties have stable student interest from matriculation to residency match in an effort to highlight which fields may be reasonable to consider for such accelerated programs. METHODS: Medical students at one school of medicine who matriculated in the years 2009-2013 were surveyed upon entry regarding the medical specialty they were most interested in pursuing. Six hundred fifty-four students were eligible for inclusion and 535 of the records met all requirements. On completion of medical school, final specialty choice for students obtaining a residency position was recorded. The data were analyzed to assess specialties with the highest versus the lowest rates of retention. RESULTS: Of 535 included students, the top specialties with retention of interest (no change in specialty choice for that student) from matriculation to match were physical medicine and rehabilitation, (100%, n=3 retention/3 initial), psychiatry (57.1%, 4/7), internal medicine (48.5%, 47/97), and family medicine (47.7%, 41/86). The specialties with the lowest retention were pathology (0%, 0/2), preventive medicine (0%, 0/4), dermatology (12%, 1/8), neurology (16.7%, 3/18) and radiation oncology (16.7%, 1/6). DISCUSSION: Some specialties that attract student interest before matriculation may be more likely to maintain interest compared to others. This suggests a need for further research to determine if residency entry can begin earlier than traditionally thought, with certain fields better suited for accelerated training.

Why medical students need addictions training.

Current medical students will be tasked at attempting to resolve the opioid epidemic in the United States that has been created by generations before them. This article will address one educator's view on the current state of training addiction treatment skills to medical students.