Optimizing evidence-based practice implementation: a case study on simulated patient protocols in long-term opioid therapy.

BACKGROUND: Substantial work has been done to update or create evidence-based practices (EBPs) in the changing health care landscape. However, the success of these EBPs is limited by low levels of clinician implementation. OBJECTIVE: The goal of this study is to describe the use of standardized/simulated patient/person (SP) methodology as a framework to develop implementation bundles to increase the effectiveness, sustainability, and reproducibility of EBPs across health care clinicians. DESIGN: We observed 12 clinicians' first-time experiences with six unique decision-making algorithms, developed previously using rigorous Delphi methods, for use with patients exhibiting concerning behaviors associated with long-term opioid therapy (LTOT) for chronic pain. Clinicians were paired with two SPs trained to portray individuals with one of the concerning behaviors addressed by the algorithms in a telehealth environment. The SP evaluations were followed by individual interviews, guided by the Consolidated Framework for Implementation Research (CFIR), with each of the clinician participants. PARTICIPANTS: Twelve primary care clinicians and 24 SPs in Western Pennsylvania. MAIN MEASUREMENT: The primary outcome was identifying likely facilitators for the successful implementation of the EBP using the SP methodology. Our secondary outcome was to assess the feasibility of using SPs to illuminate likely implementation barriers and facilitators. RESULTS: The SP portrayal illuminated factors that were pertinent to address in the implementation bundle. SPs were realistic in their portrayal of patients with concerning behaviors associated with LTOT for chronic pain, but clinicians also noted that their patients in practice may have been more aggressive about their treatment plan. CONCLUSIONS: SP simulation provides unique opportunities for obtaining crucial feedback to identify best practices in the adoption of new EBPs for high-risk patients. SETTING: Zoom simulated patient evaluations.

Assessing Patient Goals for Gender-Affirming Hormone Therapy: A Standardized Patient Case for Medical Students.

Introduction: Inadequate coverage of transgender and gender-diverse (TGD) health in the UME curriculum contributes to the scarcity of competent physicians to care for TGD patients. Increasing TGD health skills-based curricula in UME can help address TGD health disparities. We developed a standardized patient (SP) case to assess TGD health skills-based competencies and attitudes among medical students. Methods: An interdisciplinary team, including individuals with lived TGD experience, developed the SP case that was completed by second-year medical students at the University of Pittsburgh School of Medicine in January 2020. After the TGD SP session, students and faculty completed a postsession survey to assess the degree to which the case met the learning objectives. Students were assessed via self-reports, faculty reports, and SP video evaluations. Results: Seventy second-year medical students, 30 faculty facilitators, and eight SPs participated in 2020. Students reported being significantly more prepared to care for TGD patients (Z = -5.68, p < .001) and to obtain a gender history (Z = -5.82, p < .001). Both faculty and students felt that skills for caring for TGD patients were important in medical education and agreed the case should remain in the curriculum. Discussion: The case effectively honed and assessed students' ability to collect a gender history and discuss goals for hormone therapy with TGD patients. It should complement ongoing curricula to effectively train medical students in TGD health care. Developing these skills in students directly addresses the barriers that many TGD patients experience in health care settings.

A Simulated Patient Protocol for Implementing Evidence-Based Practices in Health Care Delivery.

Background: Substantial work has been done to update or create evidence-based practices (EBPs) in the changing health care landscape. However, the success of these EBPs is limited by low levels of clinician implementation. The goal of this study is to describe the use of simulated patient (SP) methodology as a framework to develop implementation bundles to increase the effectiveness, sustainability, and reproducibility of EBPs across health care clinicians. The primary outcome was identifying likely facilitators for the successful implementation of EBP. Our secondary outcome was the assess the feasibility of using SPs to illuminate likely implementation barriers and facilitators. Methods: We observed 12 primary care clinicians' first-time experiences with six unique decision-making algorithms for use with patients exhibiting concerning behaviors associated with long-term opioid therapy (LTOT) for chronic pain over Zoom. Each clinician was paired with two simulated patients trained to portray individuals with one of the concerning behaviors addressed by the algorithms. The Standardized Patient-evaluations were followed by CFIR guided one-on-one interviews with the clinicians. Results: The SP portrayal illuminated factors that were pertinent to address in the implementation bundle. SPs were realistic in their portrayal of patients with concerning behaviors associated with LTOT for chronic pain, but clinicians also noted that their patients in practice may have been more aggressive about their treatment plan. Conclusions: SP simulation provides unique opportunities for obtaining crucial feedback to identify best practices in the adoption of new EBPs for high-risk patients.

Perception of Medical Student Mistreatment: Does Specialty Matter?

PURPOSE: Medical student mistreatment is pervasive, yet whether all physicians have a shared understanding of the problem is unclear. The authors presented professionally designed trigger videos to physicians from 6 different specialties to determine if they perceive mistreatment and its severity similarly. METHOD: From October 2016 to August 2018, resident and attending physicians from 10 U.S. medical schools viewed 5 trigger videos showing behaviors that could be perceived as mistreatment. They completed a survey exploring their perceptions. The authors compared perceptions of mistreatment across specialties and, for each scenario, evaluated the relationship between specialty and perception of mistreatment. RESULTS: Six-hundred fifty resident and attending physicians participated. There were statistically significant differences in perception of mistreatment across specialties for 3 of the 5 scenarios: aggressive questioning (range, 74.1%-91.2%), negative feedback (range, 25.4%-63.7%), and assignment of inappropriate tasks (range, 5.5%-25.5%) (P ≤ .001, for all). After adjusting for gender, race, professional role, and prior mistreatment, physicians in surgery viewed 3 scenarios (aggressive questioning, negative feedback, and inappropriate tasks) as less likely to represent mistreatment compared with internal medicine physicians. Physicians from obstetrics-gynecology and "other" specialties perceived less mistreatment in 2 scenarios (aggressive questioning and negative feedback), while family physicians perceived more mistreatment in 1 scenario (negative feedback) compared with internal medicine physicians. The mean severity of perceived mistreatment on a 1 to 7 scale (7 most serious) also varied statistically significantly across the specialties for 3 scenarios: aggressive questioning (range, 4.4-5.4; P < .001), ethnic insensitivity (range, 5.1-6.1; P = .001), and sexual harassment (range, 5.5-6.3; P = .004). CONCLUSIONS: Specialty was associated with differences in the perception of mistreatment and rating of its severity. Further investigation is needed to understand why these perceptions of mistreatment vary among specialties and how to address these differences.

Perceptions of Resident Autonomy in Internal Medicine, Pediatrics, and Internal Medicine-Pediatrics.

BACKGROUND: Although graduated autonomy is an essential component of residency training, we have an incomplete understanding of resident and attending faculty perceptions of autonomy. OBJECTIVE: In this study, we assessed differences in perceived autonomy among residents and faculty in pediatrics, internal medicine, and combined internal medicine-pediatrics. METHODS: We surveyed senior-level (PGY-2-5) residents and faculty in pediatrics, internal medicine, and combined internal medicine-pediatrics in three large, urban training centers in November 2014. The survey included domain items such as general perceptions of autonomy, case management, rounding structure, and individual resident and faculty factors that may interplay with the granting or receiving of autonomy. RESULTS: Of 489 eligible respondents, 215 (44%) responded. Internal medicine-pediatrics residents were more likely than categorical pediatrics residents and pediatrics faculty to disagree that they received an appropriate level of autonomy while on inpatient pediatrics general wards (mean = 2.7 relative to 4.0 and 4.3, categorical residents and faculty; 5-point Likert scale; P < .001). On a 5-point Likert scale, the internal medicine-pediatrics residents were more likely to agree that they received too much oversight on pediatrics general ward rotations (mean, 3.9) compared to internal medicine general ward rotations (mean, 1.9) with a P-value between rotations of <.001. Combined internal medicine-pediatrics perceptions of too much oversight while on pediatric general ward rotations were significantly different from their categorical pediatrics peers (pediatrics mean 2.0, P < .001). CONCLUSIONS: Internal medicine-pediatrics residents have differing perceptions of autonomy from their categorical peers as well as categorical supervising faculty. Combined Internal medicine-pediatrics residents' perceived oversight on pediatrics rotations differently from their categorical pediatrics peers and also differently from their experiences on internal medicine wards. A better understanding of combined internal medicine-pediatrics residents' perceptions of autonomy and supervision can help inform future work regarding autonomy-supportive strategies to optimize learning.

The Use of Hybrid Lumbar Puncture Simulation to Teach Entrustable Professional Activities During a Medical Student Neurology Clerkship.

This article was migrated. The article was marked as recommended. Background: In 2014, the Association of American Medical Colleges (AAMC) published a list of 13 Entrustable Professional Activities (EPAs) that medical school graduates should be able to perform upon starting residency. The University of Pittsburgh School of Medicine (UPSOM) has surveyed our neurology clerkship students in regard to EPAs since 2017; according to this data we have been deficient in addressing EPAs 4 (enter and discuss orders/prescriptions), 11 (obtain informed consent for tests and/or procedures), and 12 (perform general procedures of a physician). We therefore developed a hybrid simulation experience encompassing these three skills, centered around lumbar puncture (LP). Methods: We created a hybrid LP simulation for students on the neurology clerkship encompassing EPAs 4, 11, and 12. Students first obtained informed consent for LP from a Standardized Patient, then performed LP on a specialized manikin. They then entered orders on CSF into a simulated patient chart. Real-time feedback was provided for all three components. Students filled out surveys to assess their perceived confidence and skill with these activities both pre- and post-simulation. Results: The percentage of students who increased their confidence with LP from minimal or less to average or more was 58.24%, 38.47%, and 26.38% for LP, informed consent, and order entry, respectively. The percentage of students who improved from not being able to perform/needing significant supervision to being able to perform with minimal supervision/ independently was 25.27%, 47.25% and 28.58%, for LP, informed consent, and order entry, respectively. These differences were all statistically significant (p Conclusions/Significance: Hybrid LP simulation was effective in increasing medical student confidence and perceived skill with EPAs 4, 11, and 12.

Recognizing Patients' Emotions: Teaching Health Care Providers to Interpret Facial Expressions.

PURPOSE: Facial expressions are an important clue to a patient's emotions. The authors developed a 90-minute workshop in May 2011 to teach physicians and physicians-in-training to interpret facial expressions and to use that skill in the context of patient care. METHOD: The workshop included a didactic presentation in which facial expression features were taught using progressively more difficult examples, followed by three interactive exercises. The authors presented the workshop at six separate venues in the United States in 2011 and 2012. To test the effectiveness of this workshop, the authors designed a comprehensive pre- and postworkshop evaluation which assessed participants' skill, knowledge, attitude (toward importance), and confidence. RESULTS: A total of 156 health care providers participated in the workshop and completed pre- and postworkshop evaluations. Participants showed substantial improvement in skill and knowledge (fact- and case-based) scores, as well as modest improvement in importance and confidence ratings. Faculty and medical students demonstrated similar baseline measures of skill, knowledge, and importance, though faculty reported a slightly higher confidence in their skills. No correlation was found between baseline ratings of confidence in abilities and any baseline measure of performance. CONCLUSIONS: Given the similar baseline performance of faculty and medical students, the ability to interpret facial expressions does not appear to be learned through routine clinical practice, highlighting the need for dedicated facial expression training. The authors were able to demonstrate that physicians and physicians-in-training could effectively learn to recognize emotion by interpreting facial expressions through a short workshop.

Perceptions of internal medicine-pediatrics residents about autonomy during residency.

BACKGROUND: The development of autonomy is a key component of residency training. Although studies have examined levels of graduated autonomy within specialties, they have not, to our knowledge, examined how residents' perceptions of autonomy differ among specialties. OBJECTIVE: We surveyed residents in internal medicine-pediatrics programs to determine their perceptions of the autonomy they experienced when they were serving on internal medicine (IM) and pediatrics inpatient rotations. METHODS: In 2012, we administered a 24-item online survey to residents in 36 internal medicine-pediatrics programs. RESULTS: Of 698 eligible residents, 143 (20.5%) participated. Participants were distributed equally among all 4 postgraduate years and between IM and pediatrics rotations. Participants were more likely to agree they experienced an appropriate level of autonomy when they were on IM rotations than when they were on pediatrics rotations (97.9% versus 34.3%, P < .001), were more likely to report experiencing frustration with too little oversight while on IM rotations (32.9% versus 2.2%, P < .001), and were more likely to report experiencing frustration with too much oversight while on pediatrics rotations (48.2% versus 0.7%, P < .001). Responses to items that described frequently encountered circumstances and hypothetical medical cases indicated participants were more likely to feel anxiety and discomfort with autonomous decision making while on pediatrics rotations. CONCLUSIONS: Residents in internal medicine-pediatrics programs perceive significant differences in the autonomy they experience during IM and pediatrics rotations. This may influence their confidence in medical decision making.