Development and Pilot Testing of a Longitudinal Skills-Based Feedback and Conflict Resolution Curriculum for Internal Medicine Residents.

PROBLEM: Physicians in training are responsible for leading clinical teams, coordinating interdisciplinary management, navigating conflict, and supervising and giving feedback to junior learners. Giving feedback and resolving conflict are key leadership skills for internal medicine (IM) residents, many of whom desire additional training. Although these skills are integral to successful leadership for physicians in training, residents receive little explicit education and existing curricula have not established best practices for skill acquisition. APPROACH: Study authors designed a pilot longitudinal, skills-based curriculum to teach first- through third-year IM residents at the University of Pittsburgh how to give formative feedback and engage in conflict resolution. From February to May 2021, authors delivered a series of interactive lectures utilizing frameworks, workplace-based scenarios, skills practice, and discussion. Skills transfer was evaluated with novel pre- and postcurriculum objective structured clinical examinations (OSCEs) wherein participants played the role of senior resident. Each OSCE involved 2 feedback and 2 conflict resolution stations. OSCE performances were evaluated using an author-created checklist with a 1-4 rating scale. The exposure group comprised post-OSCE participants who attended the curriculum. Data were analyzed using a mixed effects regression model. OUTCOMES: Thirty-six residents participated in curriculum evaluation, and 23 were included in postcurriculum data analysis. Within feedback, the skill "explores feedback content" significantly improved for exposure group participants (precurriculum median, 2.64; postcurriculum, 3.24; P < .05). For conflict resolution, among the exposure group, the skill "identifies a common goal, value, or purpose" significantly improved (pre, 3.10; post, 3.62; P < .05). NEXT STEPS: This curriculum and evaluation can serve as a stepping stone for further evidence-based leadership frameworks, curricula, and evaluations developed specifically for physicians within their unique leadership roles. The feedback and conflict resolution frameworks used in this curriculum can be applied to various medical specialties, with specialty-relevant scenario adaptations for interactive skills practice.

Female Sexual Dysfunction: A Primer for Primary Care Health Professionals.

Introduction: Female sexual dysfunction (FSD) is common and associated with decreased quality of life, relationship satisfaction, and overall well-being. However, primary care practitioners report discomfort discussing, diagnosing, and treating FSD. Methods: We delivered two sessions on the approach to evaluation and treatment of FSD: a 60-minute didactic session and a 90-minute workshop. The intended audience was primary health care professionals who care for women. The workshop utilized interactive teaching methods including a large-group discussion, case-based discussions, debrief of an observed patient-physician discussion, and language drills to develop participants' knowledge and skills. Participants were surveyed about their practice patterns and attitudes toward FSD following the sessions on a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree). Results: We collected 131 evaluations from a national Veterans Health Administration 60-minute didactic and four evaluations from the Society of General Internal Medicine Annual Meeting 90-minute workshop (response rates were 60% and 15%, respectively). One hundred thirty-five interdisciplinary trainees and practitioners from both audiences highly rated the workshop content (M = 4.1) and the overall session (M = 4.3). Didactic participants (n = 131) also reported high satisfaction (M = 4.5), increased knowledge and skills (M = 4.4), and improved interprofessional collaborative practice (M = 4.4) as a result of the training. Discussion: Our evaluation shows high satisfaction following interactive multimodal sessions on FSD. These adaptable resources can be used in multiple educational settings (didactic and workshop) and for multiple time frames to teach about FSD.

Menopause.

Menopause, which is defined as the point in time 12 months after a woman's final menstrual period, is marked by a decrease in estrogen and accompanying symptoms including vasomotor and genitourinary symptoms. Hormone therapy is the most effective treatment of vasomotor symptoms and is first-line in women with moderate-to-severe vasomotor symptoms who are early in the menopausal transition and do not have a contraindication. Nonhormonal pharmacologic and nonpharmacologic treatments are also available for the treatment of menopause-related symptoms for women who prefer to avoid hormones or who have a contraindication to hormone therapy.

Leadership Experiences of Internal Medicine Residents: A Needs Assessment for Leadership Curricula.

Purpose: Leadership development during medical training is critical. Accrediting bodies strongly recommend and residents desire leadership training. However, limited needs assessment data exist regarding trainee perceptions of and experiences with leadership training. Our objective is to describe residents' perceptions of leadership and desires for leadership training with the goal of informing effective curricular development. Patients and Methods: In 2019 a trained qualitative interviewer conducted semi-structured interviews with volunteer second-year categorical internal medicine residents recruited via email across four institutions. Interviews were audio-recorded, transcribed, and inductively coded by two independent coders. After adjudicating discrepancies, coders synthesized codes into broader themes. Final thematic analysis was triangulated with the entire author group. Results: Fourteen residents were interviewed (50% female). Few reported prior leadership training. Thematic analysis yielded six main themes. First, residents perceive "leadership" to be related to formal, assigned, hierarchical roles. Second, residents identify their own leadership primarily in the inpatient clinical setting. Third, residents identify clinical competence, emotional intelligence, and communication as important skills for effective leadership. Fourth, residents struggle to identify where leadership is currently being taught. Fifth, residents desire additional leadership development. Finally, residents prefer well-labeled, interactive methods for leadership development. Conclusion: Although residents desire leadership development, these skills are not often explicitly taught, labeled, or assessed. Curriculum developers may consider explicitly contextualizing leadership training within an "everyday leadership" framework, dovetailing leadership coaching with daily teaching workflow and feedback structures, and implementing faculty development initiatives to allow for appropriate feedback and assessment of these skills.

Retaining Providers with Women's Health Expertise: Decreased Provider Loss Among VHA Women's Health Faculty Development Program Attendees.

BACKGROUND: The Veterans Health Administration (VHA) provides care for over 500,000 women. In 2010 VHA instituted a policy requiring each facility to identify a designated women's health provider (WH-PCP) who could offer comprehensive gender-specific primary care. Access to WH-PCPs remains a challenge at some sites with high turnover among WH-PCPs. Faculty development programs have been demonstrated to foster professional development, networks, and mentorship; these can enhance job satisfaction and provide one potential solution to address WH-PCP turnover. One such program, the VHA's Women's Health Mini-Residency (WH-MR), was developed in 2011 to train WH-PCPs through case-based hands-on training. OBJECTIVE: The objective of this program evaluation was to determine the association of WH-MR participation with WH-PCP retention. DESIGN: Using the Women's Health Assessment of Workforce Capacity-Primary Care survey, we assessed the relationship between WH-MR participation and retention of WH-PCP status between fiscal year 2018 and 2019. PARTICIPANTS: All WH-PCPs (N = 2664) at the end of fiscal year 2018 were included. MAIN MEASURES: We assessed retention of WH-PCP status the following year by WH-MR participation. For our adjusted analysis, we controlled for provider gender, provider degree (MD, DO, NP, PA), women's health leadership position, number of clinical sessions per week, and clinical setting (general primary care clinic, designated women's health clinic, or a combination). KEY RESULTS: WH-MR participants were more likely to remain WH-PCPs in FY2019 in both unadjusted analyses (OR 1.91, 95%CI 1.54-2.36) and adjusted analyses (OR 1.96, 95%CI 1.58-2.44). CONCLUSIONS: WH-PCPs who participate in WH-MRs are more likely to remain WH-PCPs in the VHA system. Given the negative impact of provider turnover on patient care and the significant financial cost of onboarding a new WH-PCP, the VHA should continue to encourage all WH-PCPs to participate in the WH-MR.

Women's health update: A literature review impacting primary care.

The authors review studies on key issues in women's health with potential impact on internal medicine practice. The reviewed articles discuss cardiovascular disease risks, bone health, breast cancer genetics, cervical cancer prevention, depression in the peripartum period, pelvic pain, and emergency contraception.

BSAC Vanguard Series: Behavioural science and antimicrobial resistance.

Antimicrobial resistance could cause 10 million deaths per year by 2050 if no action is taken. While we depend on researchers to find new antimicrobials, reducing the demand for existing ones requires human behaviour change. This article by The Behavioural Insights Team discusses some of the areas with the greatest potential for behavioural interventions to reduce the development of antimicrobial resistance. Three areas are discussed: (i) 'nudging' antimicrobial stewardship (e.g. highlighting comparative over-prescribing was seen to reduce GP antibiotics prescriptions by 3.3%); (ii) promoting good hygiene practices (e.g. placement and salience of hand sanitizer increased hospital visitor compliance from 0.4% to 19.7%); and (iii) leveraging market forces (e.g. front-of-package labelling could increase demand for meat produced with minimal antibiotics, encouraging food production behaviour change).

Establishing Competencies for Leadership Development for Postgraduate Internal Medicine Residents.

BACKGROUND: Although graduate medical education accrediting bodies recognize the importance of leadership for residents and encourage curricular development, it remains unclear which competencies are most important for early career physicians to possess. OBJECTIVE: To generate a prioritized list of essential postgraduate leadership competencies to inform best practices for future curricular development. METHODS: In 2019, we used a Delphi approach, which allows for generation of consensus, to survey internal medicine (IM) physicians in leadership roles with expertise in medical education and/or leadership programming within national professional societies. Panelists ranked a comprehensive list of established leadership competencies for health care professionals, across 3 established domains (character, emotional intelligence, and cognitive skills), on importance for categorical IM residents to perform by the end of residency. Respondents also identified number of content hours and pedagogical format best suited to teach each skill. RESULTS: Sixteen and 14 panelists participated in Delphi rounds 1 and 2, respectively (88% response rate). Most were female (71%) and senior (64% in practice > 15 years, 57% full professor). All practiced in academic environments and all US regions were represented. The final consensus list included 12 "essential" and 9 "very important" leadership skills across all 3 leadership domains. Emotional intelligence and character domains were equally represented in the consensus list despite being disproportionately underweighted initially. Panelists most frequently recommended content delivery via mentorship/coaching, work-based reflection, and interactive discussion. CONCLUSIONS: This study's results suggest that postgraduate curricular interventions should emphasize emotional intelligence and character domains of leadership and prioritize coaching, discussion, and reflection for delivery.

Menopause.

This review focuses on the diagnosis and management of menopause, highlighting both hormonal and nonhormonal treatment options. In particular, the article focuses on recent data on the risks and benefits of hormone therapy to help clinicians better counsel their patients about decision making with regard to understanding and treating menopause symptoms.

Avoiding Death by Meeting: An Interactive Workshop for Academic Faculty Highlighting Strategies to Facilitate Effective Team Meetings.

Introduction: Effective meetings are a key marker of team function and are critical for task management. While important, the skill set for running an effective meeting is poorly understood. Methods: We developed an interactive curriculum that provided physician leaders in academic medicine with generalizable knowledge and skills to effectively plan and lead various types of team meetings, leverage engagement, and troubleshoot challenging personalities. This workshop (either 60 or 90 minutes) included a video-based demonstration, interactive and facilitated small- and large-group discussion, and a brief didactic to teach best practices in leading meetings. Participants included academic physicians across a spectrum of rank, specialty, and leadership experience. Knowledge, attitudes, and anticipated behavior changes were evaluated using postsurveys including 5-point Likert-type scale questions (1 = poor, 5 = outstanding) and free-text responses. Results: Fifty-seven participants rated the workshop highly with regard to content (M = 4.8), audiovisual materials (M = 4.7), and overall (M = 4.8). Most participants (82%) indicated a plan to change future design or utilization of an agenda as a result of this workshop. Feedback highlighted the need to incorporate practice opportunities in future iterations of the workshop. Discussion: Our results demonstrated that this standalone, interactive workshop focused on skills to effectively lead team meetings was well received and improved knowledge and attitudes of participants across a spectrum of rank, specialty, and leadership experience. The curriculum was time-efficient, widely generalizable, and can be easily adapted for use within academic medical centers to improve meeting effectiveness.

A Robust Faculty Development Program for Medical Educators: A Decade of Experience.

OBJECTIVES: Faculty development programs (FDPs) foster learning communities and enhance professional identity formation for medical educators. Competency-based frameworks for faculty development drive skill development across clinical practice, teaching, and scholarship domains. The aims of this study are to outline the context, content, and evolution of a novel FDP; map the individual conferences that make up the FDP to established faculty development competencies; identify steps to implement similar programming; and demonstrate outcomes to date. METHODS: The FDP consists of four, 1-hour-long conferences held weekly on a rotating basis since 2007 at the University of Pittsburgh School of Medicine: Academy of Master Educators, Medical Education Research, Medical Education Journal Club, and Medical Education Research Methods and Innovative Design conference. Authors outline the relation of each of these four conferences to faculty development competencies and describe early outcomes for each conference over four consecutive academic years from 2014 to 2018. Participants include attendees and presenters in four consecutive academic years from 2014 to 2018. RESULTS: The well-attended FDP meets all established competencies for educator faculty. Presenters and attendees were diverse in terms of academic rank and represented a breadth of clinical and basic science specialties. CONCLUSIONS: This integrated FDP fosters a community of medical educators and develops faculty skills across established medical educator competencies.

Breast Cancer Chemoprevention: A Practical Guide for the Primary Care Provider.

Several organizations, including the American Society of Clinical Oncology, the National Comprehensive Cancer Network, and the United States Preventive Services Task Force, recommend incorporation of breast cancer risk-based counseling and chemoprevention into routine well-woman care. However, primary care providers report both discomfort with and a lack of medical knowledge on this topic. In this review we present a practical, evidence-based guide for incorporating breast cancer risk assessment and chemoprevention into routine care. We advocate a stepwise approach consisting of: (1) risk assessment and communication, (2) selection of appropriate chemoprevention based on risk-benefit analysis, (3) shared decision-making regarding chemoprevention, and (4) management of chemoprevention side effects. We encourage providers to identify high-risk women and refer them to genetic counseling or a high-risk breast cancer clinic. For women who are not considered high risk, we suggest using the Gail model to estimate a woman's 5-year risk of invasive breast cancer. Usually, the benefits of chemoprevention outweigh the risks of chemoprevention once a woman's 5-year risk of invasive breast cancer reaches 3%. For these women there are several factors that need to be considered when selecting a chemoprevention agent, including patient preference, thrombotic history, menopausal status, absence or presence of a uterus, and bone mineral density. We advocate an evidence-based shared decision-making approach that reflects the woman's individual preferences when communicating risk and counseling about chemoprevention. After starting a chemoprevention agent, close follow-up is important as side effects of chemoprevention are common, including vasomotor symptoms and arthralgias. We also review evidence-based management of chemoprevention side effects.

Video Observation With Guided Reflection: A Method for Continuing Teaching Education.

BACKGROUND: Best practices for faculty development programs include longitudinal, practice-based formats incorporating experiential learning with opportunities for reflection and community building. Peer coaching for faculty development provides personalized, learner-centered, work-based learning. Implementation of traditional 1-on-1 peer coaching programs is challenging due to time, logistics, and methodological barriers. OBJECTIVE: We sought to improve observation and reflection skills and to expand personal teaching practices of clinician educators. METHODS: In 2016, we developed and evaluated an innovative "1-to-many" peer-coaching model utilizing large group review of video-recorded teaching encounters. Forty-three clinician-educator faculty in general internal medicine at the University of Pittsburgh attended at least 1 of 6 sessions between February and August 2016. Sessions were moderated by a master facilitator who guided direct observation of, and reflection on, observed teaching and highlighted efficacious teaching methods. The study evaluated the acceptability and efficacy of this novel faculty development program qualitatively, with semistructured, postcurriculum telephone interviews with 20 participating faculty. RESULTS: All respondents stated that they would continue to attend faculty development sessions and would recommend them to others. The most frequently cited advantages included exposure to new teaching strategies, direct feedback, safe environment, community of practice, and growth mind-set, yet barriers emerged, such as discomfort reviewing video, difficulty giving feedback across hierarchy, and initial skepticism. None described the curriculum as critical or unsafe. Most reported increased self-reflection and adoption of new teaching behaviors. CONCLUSIONS: This peer-coaching, video-based faculty development program was well received, feasible, and effective in changing self-reported teaching attitudes and practices.

Teaching Medical Educators How to Teach Communication Skills: More than a Decade of Experience.

OBJECTIVES: Although opportunities exist for medical educators to gain additional training in teaching, literature that describes how to teach educators to teach communication skills to trainees is limited. The authors developed and evaluated a faculty development course that uses didactics, demonstration, drills, and role-play in a small-group format. METHODS: The course has been offered through the Institute for Clinical Research Education at the University of Pittsburgh for almost 15 years. Course effectiveness was evaluated with a survey of 62 clinicians who completed the course between 2003 and 2012. RESULTS: The response rate was 85%. A total of 98% would recommend the course to a colleague and 98% indicated the course was effective at developing teaching techniques. Their use of standardized patients, teaching in small groups, and role-play increased as a result of participation in the course. A total of 70% went on to formally teach communication skills at various medical education levels. CONCLUSIONS: This structured course effectively taught participants how to teach patient-doctor communication in both classroom and clinical settings. The majority put these techniques to use in formal settings. This course also provided educators with the skills necessary to meet the growing needs of training programs charged with teaching the next generation of providers to effectively communicate with patients. The description presented can serve as a framework for faculty development in teaching communication.

An Innovative Shared Decision-Making Curriculum for Internal Medicine Residents: Findings From the University of Pittsburgh Medical Center.

PURPOSE: Shared decision making (SDM) is a core competency in health policy and guidelines. Most U.S. internal medicine residencies lack an SDM education curriculum. A standardized patient (SP)-based curriculum teaching key concepts and skills of SDM was developed. METHOD: This curriculum consisted of an innovative seven-step SDM model and a skills-focused SP case, integrated into the ambulatory rotation for senior medicine residents at the University of Pittsburgh Medical Center in 2015. Evaluation consisted of pre/postcurriculum surveys assessing residents' knowledge of and attitudes toward SDM. Skills development was assessed via pre/postcurricular audio recordings of clinical decision making. RESULTS: Thirty-six residents completed the curriculum (survey participation rate 88%). There was significant improvement in residents' knowledge (median score pre 75%, post 100%, P < .01); confidence (median composite score pre 2.87, post 3.0, P < .01, where 1 = not confident/important, 4 = very confident/important); and importance of SDM (median composite score pre 3.14, post 3.5, P < .01). Forty-four clinical recordings (31 pre, 13 post) were assessed using the Observing Patient Involvement in Decision-Making scale. Improvement in use of SDM skills was seen among all residents (mean increase 1.84 points, P = .27). When data were stratified post hoc by U.S. versus international medical graduates, there was significant improvement in total score (mean increase of 5.15 points, P = .01) among U.S. graduates only. CONCLUSIONS: SDM is teachable, and this skill-based curricular intervention resulted in improvement in senior medicine residents' knowledge of, attitudes toward, and demonstration of SDM skills.

Functional screening of five PYPAF family members identifies PYPAF5 as a novel regulator of NF-kappaB and caspase-1.

PYRIN-containing Apaf-1-like proteins (PYPAFs) are a recently identified family of proteins thought to function in apoptotic and inflammatory signaling pathways. PYPAF1 and PYPAF7 proteins have been found to assemble with the PYRIN-CARD protein ASC and coordinate the activation of NF-kappaB and pro-caspase-1. To determine if other PYPAF family members function in pro-inflammatory signaling pathways, we screened five other PYPAF proteins (PYPAF2, PYPAF3, PYPAF4, PYPAF5 and PYPAF6) for their ability to activate NF-kappaB and pro-caspase-1. Co-expression of PYPAF5 with ASC results in a synergistic activation of NF-kappaB and the recruitment of PYPAF5 to punctate structures in the cytoplasm. The expression of PYPAF5 is highly restricted to granulocytes and T-cells, indicating a role for this protein in inflammatory signaling. In contrast, PYPAF2, PYPAF3, PYPAF4 and PYPAF6 failed to colocalize with ASC and activate NF-kappaB. PYPAF5 also synergistically activated caspase-1-dependent cytokine processing when co-expressed with ASC. These findings suggest that PYPAF5 functions in immune cells to coordinate the transduction of pro-inflammatory signals to the activation of NF-kappaB and pro-caspase-1.