Opioid Management Review Committee: Fostering Interdisciplinary Education and Support Amid the Ongoing US Opioid Overdose Crisis.

BACKGROUND: Over the past two decades, pain and suffering caused by the U.S. opioid crisis have resulted in significant morbidity, policy reforms and healthcare resource strain, and affected healthcare providers' efforts to manage their patients' pain. In 2017, Cleveland Clinic's Department of Palliative and Supportive Care established their Opioid Management Review Committee (OMRC), which focuses on patient safety, opioid stewardship, education on specialist pain management and addiction medicine skills, and offers emotional and informational support to colleagues managing complex pain cases. OBJECTIVES: This quality assessment and improvement activity describes the organization and effects of the OMRC on healthcare workers in the department. METHODS: On February 1, 2023, an online survey was distributed to attendees of the OMRC. Participants were asked to provide their demographic information and free text responses to questions about the purpose of the OMRC, their judgment about the extent to which the OMRC has changed their approach to pain management, the OMRC's impact on their approach to opioid management, its impact on the clinicians' confidence in managing nonmedical opioid use or comorbid substance use, and suggestions to improve future meetings. RESULTS: Fifty-nine out of 79 clinicians completed the survey (75% response rate). Participants' aggregate responses indicated that the committee fostered interdisciplinary collaboration, provided emotional and professional support, increased awareness of responsible opioid prescribing, and enhanced confidence in managing complex cases involving non-medical opioid use or comorbid substance use. CONCLUSION: The OMRC represents a comprehensive interdisciplinary approach to safely manage opioid therapy during the contemporary opioid overdose crisis.

Guardianship: The Implications of Resident Physician Perceptions of Caring for Incapacitated Older Adults Without Advocates.

As the incidence of dementia rises, increased utilization of surrogate decision-makers, including legal guardians, is anticipated. This manuscript presents an analysis of resident physicians' experiences and perceptions regarding requirements, roles, and responsibilities of caring for older adults in need of, or already under, legal guardianship. This is a cross-sectional study, conducted at a tertiary academic medical center. A survey was sent, via Qualtrics, to all emergency medicine, family medicine, internal medicine, general surgery, and medicine-pediatric resident physicians. Eighty-eight out of three hundred thirty-three (26.4%) eligible residents physicians completed the survey. Most (98.9%) reported caring for patients under guardianship, yet many resident physicians reported significant uncertainty regarding the roles and responsibilities of guardianship, including its potential benefits and limitations. They also displayed misconceptions and overconfidence about guardians' abilities to facilitate disposition, ensure financial security, and assign code status, among other matters. Our study highlights the importance of structured and directed education on the topic of guardianship for medical trainees.

A multimedia paediatric cardiology assessment tool for medical students and general paediatric trainees: development and validation.

BACKGROUND: Understanding how cardiovascular structure and physiology guide management is critically important in paediatric cardiology. However, few validated educational tools are available to assess trainee knowledge. To address this deficit, paediatric cardiologists and fellows from four institutions collaborated to develop a multimedia assessment tool for use with medical students and paediatric residents. This tool was developed in support of a novel 3-dimensional virtual reality curriculum created by our group. METHODS: Educational domains were identified, and questions were iteratively developed by a group of clinicians from multiple centres to assess understanding of key concepts. To evaluate content validity, content experts completed the assessment and reviewed items, rating item relevance to educational domains using a 4-point Likert scale. An item-level content validity index was calculated for each question, and a scale-level content validity index was calculated for the assessment tool, with scores of ≥0.78 and ≥0.90, respectively, representing excellent content validity. RESULTS: The mean content expert assessment score was 92% (range 88-97%). Two questions yielded ≤50% correct content expert answers. The item-level content validity index for 29 out of 32 questions was ≥0.78, and the scale-level content validity index was 0.92. Qualitative feedback included suggestions for future improvement. Questions with ≤50% content expert agreement and item-level content validity index scores <0.78 were removed, yielding a 27-question assessment tool. CONCLUSIONS: We describe a multi-centre effort to create and validate a multimedia assessment tool which may be implemented within paediatric trainee cardiology curricula. Future efforts may focus on content refinement and expansion to include additional educational domains.

Virtual reality curriculum increases paediatric residents' knowledge of CHDs.

OBJECTIVES: Virtual reality has emerged as a unique educational modality for medical trainees. However, incorporation of virtual reality curricula into formal training programmes has been limited. We describe a multi-centre effort to develop, implement, and evaluate the efficacy of a virtual reality curriculum for residents participating in paediatric cardiology rotations. METHODS: A virtual reality software program ("The Stanford Virtual Heart") was utilised. Users are placed "inside the heart" and explore non-traditional views of cardiac anatomy. Modules for six common congenital heart lesions were developed, including narrative scripts. A prospective case-control study was performed involving three large paediatric residency programmes. From July 2018 to June 2019, trainees participating in an outpatient cardiology rotation completed a 27-question, validated assessment tool. From July 2019 to February 2020, trainees completed the virtual reality curriculum and assessment tool during their cardiology rotation. Qualitative feedback on the virtual reality experience was also gathered. Intervention and control group performances were compared using univariate analyses. RESULTS: There were 80 trainees in the control group and 52 in the intervention group. Trainees in the intervention group achieved higher scores on the assessment (20.4 ± 2.9 versus 18.8 ± 3.8 out of 27 questions answered correctly, p = 0.01). Further analysis showed significant improvement in the intervention group for questions specifically testing visuospatial concepts. In total, 100% of users recommended integration of the programme into the residency curriculum. CONCLUSIONS: Virtual reality is an effective and well-received adjunct to clinical curricula for residents participating in paediatric cardiology rotations. Our results support continued virtual reality use and expansion to include other trainees.

Eating Problems in Advanced Dementia: Navigating Difficult Conversations.

Introduction: The majority of older adults with advanced dementia (AD) develop difficulties with eating and swallowing, often prompting concerns about nutrition and quality of life. Employing a palliative approach requires providers to attain skills in addressing symptoms and communicating with family caregivers about the trajectory of AD and associated dysphagia, as well as to elicit goals of care. Research suggests internal medicine (IM) residents often perceive minimal education during training addressing skills needed to care for patients with AD. Methods: We developed and piloted a small-group interactive seminar utilizing a trigger video depicting a family meeting addressing eating problems in a patient with AD. Case-based learning, small-group discussion, and learner reflection were employed. We assessed the impact on 82 of the 106 IM, medicine-pediatrics, and neurology residents who participated in the seminar. Results: Participant evaluation indicated residents showed high satisfaction and perceived the educational content of the seminar to be robust and clinically relevant. We found statistically significant (p < .001) improvements in self-reported confidence in dementia-specific skills postseminar. Effect size was large to very large (Cohen's d = 1.3-1.7). Discussion: An interactive, case-based seminar utilizing a video depicting a realistic family meeting improved residents' self-efficacy in skills needed to address nutritional issues, engage in goals-of-care discussions, and reflect on concerns among caregivers of patients with AD. The seminar teaches important geriatric and palliative concepts meant to improve residents' ability to care for older adults with AD in their future careers.

A Pilot Interprofessional Course on Substance Use Disorders to Improve Students' Empathy and Counseling Skills.

Objective. To implement and assess the effectiveness of an interprofessional course designed to provide pharmacy and nursing students with opportunities to improve their understanding of substance use disorders (SUDs), assess their attitudes toward patients with SUDs, receive instruction and feedback on behavior change counseling, and engage in interprofessional education. Methods. The course consisted of four interactive class sessions that focused on empathy and recognition of personal bias, behavioral change counseling, and SUD recognition, screening, and treatment. Classes were taught by an interprofessional faculty member. Students also attended a 12-step recovery meeting in the community, counseled an authentic patient using behavioral change counseling, and received feedback based on a faculty member's direct observation of their counseling. Students completed validated assessments of their attitudes toward patients with SUDs and interprofessional collaboration. A faculty member used the Behavioral Change Counseling Index (BECCI) to assess students' counseling of SUD patients. Counseled patients were asked their preference for follow-up care for their SUD. Results. Twenty-seven pharmacy and nursing students completed this course, along with 51 students from other professions. The pharmacy and nursing students demonstrated significant improvements in their attitudes toward patients with SUDs and toward interprofessional collaboration, as measured by the Substance Abuse Attitudinal Scale (SAAS) and Student Perception of Interprofessional Clinical Education (SPICE-R2). Approximately 93% of pharmacy and nursing students counseled a patient with a SUD, with 96% of counseled patients reporting their intent to receive follow-up care. Conclusion. An interprofessional SUD course enriched pharmacy and nursing students' understanding, attitudes, and behaviors toward patients with SUDs and interprofessional collaboration. Students demonstrated an ability to provide behavior change counseling to patients, and 96% of counseled patients stated a willingness for follow-up care for their SUD.

Behavior Change Counseling of Patients with Substance Use Disorders by Health Professions Students.

OBJECTIVE: The purpose of this project was to create an interprofessional substance use disorders (SUDs) course that provided health professions students an opportunity to acquire and apply behavior change counseling skills for patients with SUDs with direct observation, assessment, and feedback. METHODS: The interprofessional SUDs course was offered five times within one academic year as part of a one-month psychiatry clerkship. The course focused on developing empathy and examining personal bias, behavioral change counseling, and recognition, screening, and treatment of SUDs. Students practiced behavior change counseling during the course and with a SUD patient. A faculty member experienced in behavior change counseling assessed students' patient counseling using the validated Behavior Change Counseling Index (BECCI). RESULTS: Seventy-eight students from medicine, nursing, pharmacy, social work, and physician assistant programs completed the one-month course. Fifty-three students counseled a SUD patient. Students' BECCI-rated counseling skills indicated they performed recommended counseling practices and spoke "less than half the time" or "about half the time" when counseling. Ninety-three percent of SUD patients reported a willingness for follow-up care about their substance use after the student-led session with a student. CONCLUSION: Following participation in an innovative interprofessional SUD course that included behavior change counseling, students demonstrated their ability to apply their skills during training and with a SUD patient. The study demonstrated promising patient outcomes following student counseling.

An Interprofessional Substance Use Disorder Course to Improve Students' Educational Outcomes and Patients' Treatment Decisions.

PURPOSE: Substance use is a public health concern. Health professions organizations recommend improvements in substance use disorder (SUD) education. Mezirow's transformative learning theory was used as the educational framework to develop a course that would provide students with opportunities to improve their understanding of SUDs; to assess, challenge, and reflect on their attitudes toward patients with SUDs; to receive direct observation, assessment, and feedback on behavior change counseling; and to engage in interprofessional education. The study's purpose was to evaluate the impact of an interprofessional SUD course on students' educational outcomes and their attitudes toward interprofessionalism. METHOD: Students from several health professions-medicine, pharmacy, physician assistant, nursing, and social work-attended a monthly interprofessional education SUD course starting in spring 2018. The course, taught by an interprofessional faculty, consisted of 4 interactive classes focused on empathy and recognizing personal bias; behavioral change counseling; and recognition, screening, and treatment of SUDs. Students attended a 12-step recovery meeting and had an optional opportunity to counsel a patient using behavioral change counseling. RESULTS: Seventy-eight students completed the course. Students demonstrated significant improvements in their attitudes toward patients with SUDs and toward interprofessionalism, as measured by the Substance Abuse Attitude Survey and the Student Perceptions of Interprofessional Clinical Education survey. Nearly 70% of students counseled a patient with an SUD, and 93% of counseled patients agreed to follow-up care. CONCLUSIONS: The course (1) enriched students' understanding, attitudes, and behaviors toward patients with SUDs and toward interprofessional collaboration and (2) positively influenced patients' treatment decisions.

Scaling Up a Global Health and Disparities Path of Excellence Pilot Program at the University of Michigan Medical School.

PROBLEM: Transforming medical school curricula to train physicians to better address society's needs is a complex task, as students must develop expertise in areas other than clinical medicine. APPROACH: In 2010, the University of Michigan Medical School (UMMS) launched the Global Health and Disparities (GHD) Path of Excellence as part of a larger curriculum transformation. The GHD Path is a co-curriculum with the goal of ameliorating health disparities in the United States and abroad. It was developed iteratively based on student and faculty feedback. Student feedback emphasized the value of the relationships with faculty and other students, the capstone project, and exposure to role models and professional networks. Faculty described the joy of interacting with students and the desire for recognition by their departments for their role as an advisor. OUTCOMES: Informed by the GHD Path experience, UMMS embraced the Path model, which emphasized professional relationships, career development, and high-impact scholarly work, making it different from the traditional medical curriculum, and the school implemented 7 other Paths between 2013 and 2018. Elements common to all Paths include a capstone project, a longitudinal advisor separate from the capstone advisor, exposure to role models and leaders, and the dissemination of scholarly work to promote networking. NEXT STEPS: Next steps for the Paths of Excellence include developing methods to systematically monitor students' progress, facilitating mentoring skills in and recognizing faculty advisors, and measuring the long-term impact of the Paths on students and society.

Co-teaching in an Undergraduate Clinical Skills Course: Physicians and Social Behavioural Scientists Use a Shared Mental Model to Highlight Complementary Aspects of Medical Interviewing and Physical Exam Skills.

This article was migrated. The article was marked as recommended. Introduction: Interdisciplinary co-teaching by physicians (MD) and social behavioural scientists (SBS) has emerged as an innovative teaching practice in clinical skills courses, but little is known about how co-teachers operationalize instruction. The purpose of this study was to explore the shared mental model of co-teachers concerning medical interviewing and physical examination instruction. Methods: Twelve individual semi-structured interviews were conducted at Brown University. Participants were asked, " What and how do MD and SBS faculty contribute to teaching medical interviewing and physical examination skills?" Transcripts were subjected to thematic analysis. Discourse analysis was also used to determine if what faculty individually described as contributing to instruction was observed by the co-teacher. Results: Physician and SBS faculty emphasized different but complementary aspects of medical interviewing and physical examination skills. Physicians focused on content, targeting clinical reasoning, differential diagnosis, economy of movement, efficiency, synthesis, and technical skills. SBS faculty focused on process,emphasizing active listening, presence, non-verbal communication, rapport building, empathy, and patient comfort. Discussion: Co-teachers consistently articulated their relative contributions to teaching medical interviewing and physical examinations. Their shared mental model emphasized the importance of both content and process, creating a learning environment supporting the development of both biomedical and patient-centred perspectives.

Designing a Curriculum for Professionalism and Ethics Within Radiology: Identifying Challenges and Expectations.

Although professionalism and ethics represent required competencies, they are more challenging than other competencies to design a curriculum for and teach. Reasons include variability in agreed definitions of professionalism within medicine and radiology. This competency is also framed differently whether as roles, duties, actions, skills, behavior, beliefs, and attitudes. Standardizing a curriculum in professionalism is difficult because each learner's (medical student/resident) professional experiences and interactions will be unique. Professionalism is intertwined throughout all (sub) specialties and areas and its teaching cannot occur in isolation as a standalone curriculum. In the past, professionalism was not emphasized enough or at all, with global (or no) assessments, with the potential effect of trainees not valuing it. Although we can teach it formally in the classroom and informally in small groups, much of professionalism is witnessed and learned as "hidden curricula". The formal, informal, and hidden curricula often contradict each other creating confusion, disillusion, and cynicism in trainees. The corporatization of medicine pressurizes us to increase efficiency (throughput) with less focus on aspects of professionalism that add value, creating a disjoint between what we do in practice and preach to trainees. Progressively, expectations for our curriculum include providing evidence for the impacts of our efforts on patient outcomes. Generational differences in the perception of professionalism and the increasingly diverse and multicultural society in which we live affects our interpretation of professionalism, which can add to confusion and misunderstanding. The objectives of this article are to outline challenges facing curriculum design in professionalism and to make suggestions to help educators avoid or overcome them.

Teaching and Assessing Professionalism in Radiology: Resources and Scholarly Opportunities to Contribute to Required Expectations.

Teaching and assessing trainees' professionalism now represents an explicit expectation for Accreditation Council Graduate Medical Education-accredited radiology programs. Challenges to meeting this expectation include variability in defining the construct of professionalism; limits of traditional teaching and assessment methods, used for competencies historically more prominent in medical education, for professionalism; and emerging expectations for credible and feasible professionalism teaching and assessment practices in the current context of health-care training and practice. This article identifies promising teaching resources and methods that can be used strategically to augment traditional teaching of the cognitive basis for professionalism, including role modeling, case-based scenarios, debriefing, simulations, narrative medicine (storytelling), guided discussions, peer-assisted learning, and reflective practice. This article also summarizes assessment practices intended to promote learning, as well as to inform how and when to assess trainees as their professional identities develop over time, settings, and autonomous practice, particularly in terms of measurable behaviors. This includes assessment tools (including mini observations, critical incident reports, and appreciative inquiry) for authentic assessment in the workplace; engaging multiple sources (self-, peer, other health professionals, and patients) in assessment; and intentional practices for trainees to take responsibility for seeking our actionable feedback and reflection. This article examines the emerging evidence of the feasibility and value added of assessment of medical competency milestones, including professionalism, coordinated by the Accreditation Council Graduate Medical Education in radiology and other medical specialties. Radiology has a strategic opportunity to contribute to scholarship and inform policies in professionalism teaching and assessment practices.

Teaching and Assessing Professionalism in Radiology Resident Education.

Radiologists in teaching hospitals and in practices with residents rotating through are involved in the education of their residents. The Accreditation Council for Graduate Medical Education requires evidence that trainees are taught and demonstrate competency not only in medical knowledge and in patient care-the historic focus of radiology education-but also in the so-called non-interpretative core competencies, which include professionalism and interpersonal skills. In addition to accreditation agencies, the prominent assessment practices represented by the American Board of Radiology core and certifying examinations for trainees, as well as Maintenance of Certification for practitioners, are planning to feature more non-interpretative competency assessment, including professionalism to a greater extent. Because professionalism was incorporated as a required competency in medical education as a whole, more clarity about the justification and expected content for teaching about competence in professionalism, as well as greater understanding and evidence about appropriate and effective teaching and assessment methods, have emerged. This article summarizes justifications and expectations for teaching and assessing professionalism in radiology residents and best practices on how to teach and evaluate professionalism that can be used by busy radiology faculty in their everyday practice supervising radiology residents.

Primary Care Residents Improve Knowledge, Skills, Attitudes, and Practice After a Clinical Curriculum With a Hospice.

Effective approaches to teaching attitudes, knowledge, and skills to resident physicians in primary care that can be implemented in any residency program are needed. We examined the feasibility and impact of a single palliative care residency curriculum, including a clinical rotation with a hospice program, across 5 cohorts of residents in 7 divergent primary care residency programs (both family medicine and internal medicine). The didactic content was drawn from the national Education for Physicians on End-of-Life Care Project. A total of 448 residents completed the curriculum. A large effect size was seen in measures of knowledge change (*Cohen d = .89) when compared to a national sample of primary care residency programs. Additionally, measures of confidence to perform palliative care skills and ethical concerns also improved significantly ( P < .001). A frequent comment is wishing the rest of medicine were like that experienced in the hospice setting. In a separate, ancillary evaluation, the average length of stay of patients enrolled in hospice care was 18.5 days longer for the alumni of this program when compared to physicians referring for hospice care who hadn't experienced the curriculum.

Scholarly Concentration Program Development: A Generalizable, Data-Driven Approach.

PURPOSE: Scholarly concentration programs-also known as scholarly projects, pathways, tracks, or pursuits-are increasingly common in U.S. medical schools. However, systematic, data-driven program development methods have not been described. METHOD: The authors examined scholarly concentration programs at U.S. medical schools that U.S. News & World Report ranked as top 25 for research or primary care (n = 43 institutions), coding concentrations and mission statements. Subsequently, the authors conducted a targeted needs assessment via a student-led, institution-wide survey, eliciting learners' preferences for 10 "Pathways" (i.e., concentrations) and 30 "Topics" (i.e., potential content) augmenting core curricula at their institution. Exploratory factor analysis (EFA) and a capacity optimization algorithm characterized best institutional options for learner-focused Pathway development. RESULTS: The authors identified scholarly concentration programs at 32 of 43 medical schools (74%), comprising 199 distinct concentrations (mean concentrations per program: 6.2, mode: 5, range: 1-16). Thematic analysis identified 10 content domains; most common were "Global/Public Health" (30 institutions; 94%) and "Clinical/Translational Research" (26 institutions; 81%). The institutional needs assessment (n = 468 medical students; response rate 60% overall, 97% among first-year students) demonstrated myriad student preferences for Pathways and Topics. EFA of Topic preferences identified eight factors, systematically related to Pathway preferences, informing content development. Capacity modeling indicated that offering six Pathways could guarantee 95% of first-year students (162/171) their first- or second-choice Pathway. CONCLUSIONS: This study demonstrates a generalizable, data-driven approach to scholarly concentration program development that reflects student preferences and institutional strengths, while optimizing program diversity within capacity constraints.

Competency-based education: programme design and challenges to implementation.

CONTEXT: Competency-based education (CBE) has been widely cited as an educational framework for medical students and residents, and provides a framework for designing educational programmes that reflect four critical features: a focus on outcomes, an emphasis on abilities, a reduction of emphasis on time-based training, and promotion of learner centredness. Each of these features has implications and potential challenges for implementing CBE. METHODS: As an experiment in CBE programme design and implementation, the University of Michigan Master of Health Professions Education (UM-MHPE) degree programme was examined for lessons to be learned when putting CBE into practice. The UM-MHPE identifies 12 educational competencies and 20 educational entrustable professional activities (EPAs) that serve as the vehicle for both learning and assessment. The programme also defines distinct roles of faculty members as assessors, mentors and subject-matter experts focused on highly individualised learning plans adapted to each learner. CONCLUSIONS: Early experience with implementing the UM-MHPE indicates that EPAs and competencies can provide a viable alternative to traditional courses and a vehicle for rigorous assessment. A high level of individualisation is feasible but carries with it significant costs and makes intentional community building essential. Most significantly, abandoning a time-based framework is a difficult innovation to implement in a university structure that is predicated on time-based education.

You have no Choice but to go on: How Physicians and Midwives in Ghana Cope with High Rates of Perinatal Death.

Objectives Healthcare providers in low-resource settings confront high rates of perinatal mortality. How providers cope with such challenges can affect their well-being and patient care; we therefore sought to understand how physicians and midwives make sense of and cope with these deaths. Methods We conducted semi-structured interviews with midwives, obstetrician-gynecologists, pediatricians and trainee physicians at a large teaching hospital in Kumasi, Ghana. Interviews focused on participants' coping strategies surrounding perinatal death. We identified themes from interview transcripts using qualitative content analysis. Results Thirty-six participants completed the study. Themes from the transcripts revealed a continuum of control/self-efficacy and engagement with the deaths. Providers demonstrated a commitment to push on with their work and provide the best care possible. In select cases, they described the transformative power of attitude and sought to be agents of change. Conclusions Physicians and midwives in a low-resource country in sub-Saharan Africa showed remarkable resiliency in coping with perinatal death. Still, future work should focus on training clinicians in coping and strengthening their self-efficacy and engagement.