Leadership Development in Graduate Medical Education: A Pilot Study of Implementation of a Validated Self-assessment Instrument.

BACKGROUND AND OBJECTIVES: Graduate medical education programs need leadership assessments and curricula to engage residents and advance their leadership skills. The Foundational Healthcare Leadership Self-assessment (FHLS) is a validated 21-item self-assessment of leadership skills residents need to be effective team leaders in health care settings. It generates a composite score along five foundational leadership domains: accountability, collaboration, communication, team management, and self-management. Our objective was to determine whether a leadership curriculum, using the FHLS as an educational tool to support self-assessment, self-directed learning, and reflective practice, promotes self-awareness and engagement in leadership development. METHODS: We conducted a qualitative pilot study in the University of Utah Family Medicine Residency Program, integrating the FHLS into our residency's longitudinal leadership curriculum using coaching, self-directed learning, and reflective practice. Family medicine residents completed the FHLS prior to their leadership rotation. Faculty met with each resident during their rotation using a coaching paradigm based on data from the FHLS to inform leadership self-awareness. Residents identified a leadership domain for self-improvement, selected resources for self-study, and submitted a written reflection. We conducted qualitative content analysis on the reflections for evidence of self-awareness and engagement in leadership development. RESULTS: Residents completed 27 leadership rotations between May 2019 and April 2020, generating 21 reflections. Qualitative content analysis of resident reflections grouped by FHLS leadership domains identified evidence of impact on the residents' leadership development. CONCLUSIONS: This qualitative pilot study supports the usefulness of the FHLS within a residency leadership curriculum to promote self-awareness and engagement in leadership development.

Impact of Virtual Recruitment on Costs, Time Spent, and Applicant Perspectives Within a Family Medicine Residency Program.

Background: Virtual recruitment for all residency programs was endorsed by the Accreditation Council for Graduate Medical Education (ACGME) for the 2021 and 2022 recruitment seasons. This study assesses the impact of virtual recruitment on cost and outcome in a family medicine residency program. Methods: We assessed program recruitment costs and interview-day time with applicants in one program for the 2019 to 2022 recruitment seasons, and we sent an anonymous survey to interviewed applicants (n=98) for the 2022 match year. In-person interviews were conducted in 2019 and 2020. Virtual interviews were conducted in 2021 and 2022. Results: Program recruitment costs decreased from over $70,000 annually for in-person interview seasons to between $10,000 and $20,000 annually for the virtual interview years. Applicant time with the program on interview days decreased from 515 minutes when held in-person, to 345 minutes when virtual. Applicants expressed that they were generally satisfied with the virtual interview format though their preference for the virtual format was only slightly greater than for in-person interviews (38.6% and 35.1%, respectively); 26.3% of the responding applicants had no preference for either format. During virtual interview years, applicants interviewed at an average of 16.6 programs with 80% indicating that virtual interviews allowed for consideration of more programs. Conclusion: The virtual interview format was associated with decreased interview-day costs for programs and interviewees, and decreased time on interview days for both groups. It allowed applicants to consider more programs.

Teaching Self-directed Learning Skills Through a Resident-Led Milestones Process.

Introduction: The Accreditation Council for Graduate Medical Education allows flexibility for resident roles in the Milestone assessment process. The University of Utah Family Medicine Residency implemented a resident-led Milestones process to cultivate the skill of self-assessment and promote resident ownership of their learning. Methods: Residents were provided comprehensive evaluation data and asked to self-assess their competency on each Milestone, with input from their advisor. Residents presented their self-assessment to the Clinical Competency Committee, who then determined the final score for each Milestone. A 10-question survey examined perceptions of the resident-led Milestones process by residents and faculty. We calculated means and standard deviations (SD). Results: A total of 16 of 24 residents (67% response rate) and 12 of 14 faculty (86% response rate) completed the survey. Residents agreed most highly with the following statements: "I have good support from my advisor in being prepared to lead my Milestones meeting," "I am actively engaged in guiding the development of my own Milestones ratings," and "Leading my Milestones meeting assists me in accurately self-assessing my progress." Residents showed high agreement that "My final Milestones scores accurately reflect my behavior and level of knowledge." Residents rated the stress as low, in response to the statement, "My Milestones meeting is stressful for me." Faculty responses were similar but tended toward lower scores than residents. Conclusion: The resident-led Milestones process engages residents actively in self-assessment. Residents and faculty believe the process provides accurate assessment results without undue stress; this process potentially increases residents' ability to understand their own learning needs and direct their own learning process.

Provider detailing: an intervention to decrease prescription opioid deaths in Utah.

BACKGROUND: Utah undertook a multipronged effort to reverse an epidemic of deaths among patients taking prescription opioids. This article describes the provider detailing portion of the effort. METHODS: Presentations highlighting six recommended prescribing practices were developed and presented to health care workers. Participants were encouraged to utilize the state prescription database and to complete a series of surveys assessing confidence and behavior changes at 0, 1, and 6 months post-presentation. Continuing medical education credits incentivized participation. RESULTS: Utah's medication-related overdose deaths dropped 14.0% in 2008 compared with 2007 following program implementation. A total of 581 physicians and numerous nonphysician health care workers were reached during 46 presentations. Follow-up surveys regarding the degree of adoption of practice changes were completed by 366 participants at 0 months, 82 participants at 1 month, and 29 participants at 6 months. Combined results for all three evaluations showed that 60-80% of responding providers reported no longer prescribing long-acting opioids for acute pain or with sedatives; 50% noted using Utah's controlled substances database during patient care and utilizing lower starting doses and slower escalations; and 30-50% reported obtaining EKGs and sleep studies on appropriate patients, using patient education tools, and implementing Utah's prescribing guidelines. CONCLUSIONS: Provider detailing was associated with a decrease in Utah's prescription opioid death rate and improvements in provider self-reported prescribing behaviors. Other simultaneous interventions may have contributed to the decline in death rates. This intervention's effect was limited by short-term funding.

An analysis of the root causes for opioid-related overdose deaths in the United States.

OBJECTIVE: A panel of experts in pain medicine and public policy convened to examine root causes and risk factors for opioid-related poisoning deaths and to propose recommendations to reduce death rates. METHODS: Panelists reviewed results from a search of PubMed and state and federal government sources to assess frequency, demographics, and risk factors for opioid-related overdose deaths over the past decade. They also reviewed results from a Utah Department of Health study and a summary of malpractice lawsuits involving opioid-related deaths. RESULTS: National data demonstrate a pattern of increasing opioid-related overdose deaths beginning in the early 2000s. A high proportion of methadone-related deaths was noted. Although methadone represented less than 5% of opioid prescriptions dispensed, one third of opioid-related deaths nationwide implicated methadone. Root causes identified by the panel were physician error due to knowledge deficits, patient non-adherence to the prescribed medication regimen, unanticipated medical and mental health comorbidities, including substance use disorders, and payer policies that mandate methadone as first-line therapy. Other likely contributors to all opioid-related deaths were the presence of additional central nervous system-depressant drugs (e.g., alcohol, benzodiazepines, and antidepressants) and sleep-disordered breathing. CONCLUSIONS: Causes of opioid-related deaths are multifactorial, so solutions must address prescriber behaviors, patient contributory factors, nonmedical use patterns, and systemic failures. Clinical strategies to reduce opioid-related mortality should be empirically tested, should not reduce access to needed therapies, should address risk from methadone as well as other opioids, and should be incorporated into any risk evaluation and mitigation strategies enacted by regulators.

Impact of Pharmacist Previsit Input to Providers on Chronic Opioid Prescribing Safety.

INTRODUCTION: Primary care providers (PCPs) account for half of opioid prescriptions, often feel chronic pain patients are challenging to manage, and there is wide variability in practice patterns. The purpose of this pilot study was to evaluate the impact of a previsit pharmacist review of high-risk patients treated with opioids for chronic pain on compliance to guideline recommendations at a family medicine residency clinic. METHODS: All adult patients with an appointment for chronic pain who were prescribed >50 morphine milligram equivalents (MMEs)/day had charts reviewed by a pharmacist before each appointment; recommendations were sent electronically to the provider before the appointment. After 4 months of implementation, each patient's chart was manually reviewed to gather outcome variables. The primary outcomes were the mean MMEs/day and pain scores. RESULTS: Pharmacist previsit recommendations were provided for 45 patients. When comparing outcomes before and after intervention, the mean MMEs/day decreased by 14% (P < .001), with no change in pain scores (P = .783). Statistically significant improvements were noted in multiple other secondary opioid safety outcomes. CONCLUSION: Clinical pharmacists providing previsit recommendations was associated with decreased opioid utilization with no corresponding increase in pain scores and increased compliance to guideline recommendations.

Development and Validation of the Foundational Healthcare Leadership Self-assessment.

BACKGROUND AND OBJECTIVES: We sought to develop and validate a self-assessment of foundational leadership skills for early-career physicians. METHODS: We developed a leadership self-assessment from a compilation of materials on health care leadership skills. A sequential exploratory study was conducted using qualitative and quantitative analysis for face, content, and construct validity of the self-assessment. First, two focus groups were conducted with leaders in medicine and family medicine residents, to refine the pilot self-assessment. The self-assessment pilot was then tested with family medicine residents across the country, and the results were quantitatively evaluated with principal component analysis. This data was used to reduce and group the statements into leadership domains for the final self-assessment. RESULTS: Twenty-two invited family medicine residency programs agreed to distribute the survey. A total of 163 family medicine residents completed the survey, representing 16 to 20 residency programs from 12 states (response rate 28.9% to 34.8%). Analysis showed important differences by residency year, with more advanced residents scoring higher. The analysis reduced the number of items from 33 on the pilot assessment to 21 on the final assessment, which the authors titled the Foundational Healthcare Leadership Self-assessment (FHLS). The 21 items were grouped into five leadership domains: accountability, collaboration, communication, team management, and self-management. CONCLUSIONS: The FHLS is a validated 21-item self-assessment of foundational leadership skills for early career physicians. It takes less than 5 minutes to complete, and quantifies skill within five domains of foundational leadership. The FHLS is a first step in developing educational and evaluative assessments for training medical residents as clinician leaders.

Cardiac issues in the young athlete.

Young athletes are disproportionately plagued with congenital cardiac disease. Many of these diseases predispose to sudden cardiac death (SCD), a dramatic and tragic outcome for any young athlete. In many cases, conditions that predispose to SCD do not cause symptoms or show signs on examination, making diagnosis of cardiac disease and prevention of SCD difficult. Clinicians should be familiar with common causes of SCD and their symptoms, perform careful evaluations, refer athletes in whom there are concerns, and make sure any concerning findings receive thorough evaluation. Clinicians should also be familiar with and follow recent guidelines on return to play. Unfortunately, most preparticipation examinations are inadequate, due in part to use of inadequate forms. Better forms are available and should replace inadequate ones.

CERA: Clerkships Need National Curricula on Care Delivery, Awareness of Their NCC Gaps.

BACKGROUND AND OBJECTIVES: The Society of Teachers of Family Medicine's (STFM) National Clerkship Curriculum (NCC) was created to standardize and improve teaching of a minimum core curriculum in family medicine clerkships, promoting the Triple Aim of better care and population health at lower cost. It includes competencies all clerkships should teach and tools to support clerkship directors (CDs). This 2014 CERA survey of clerkship directors is one of several needs assessments that guide STFM's NCC Editorial Board in targeting improvements and peer-review processes. METHODS: CERA's 2014 survey of CDs was sent to all 137 CDs at US and Canadian allopathic medical schools. Primary aims included: (1) Identify curricular topics of greatest need, (2) Inventory the percent of family medicine clerkships teaching each NCC topic, and (3) Determine if longitudinal or blended clerkship have unique needs. This survey also assessed use of NCC to advocate for teaching resources and collaborate with colleagues at other institutions. RESULTS: Ninety-one percent of CDs completed the survey. Sixty-four percent reported their clerkship covers all of the NCC minimum core, but on detailed analysis, only 1% teach all topics. CDs need curricula on care delivery topics (cost-effective approach to acute care, role of family medicine in the health care system, quality/safety, and comorbid substance abuse). CONCLUSIONS: Single-question assessments overestimate the percentage of clerkships teaching all of the NCC minimum core. Clerkships need national curricula on care delivery topics and tools to help them find their curricular gaps.

Caring for the underserved: using patient and physician focus groups to inform curriculum development.

BACKGROUND: Training pediatric residents to care for the underserved is a recognized curricular need. A literature review revealed that curricula specific to caring for the underserved tend to focus on specific medical diagnoses rather than physician or patient behaviors. OBJECTIVE: To collect and evaluate information essential for developing a curriculum to teach care for the underserved. METHODS: Focus groups were conducted to identify themes responsive to the question, "What does a physician need to know to care for the underserved?" Each of 3 focus groups met twice. The physician group included 5 pediatricians and 3 family practitioners. There were 2 patient groups: one Spanish-speaking (N = 13) and one English-speaking (N = 8). Content analysis was used to identify themes from each of the focus groups. RESULTS: Prevailing themes from the 3 groups were communication/respect, cultural issues, and frustration with systems, such as health insurance, transportation, and health delivery systems. Patients expressed an almost universal wish for physicians to listen to them and to attempt to "understand my life." Physicians expressed concerns with lacking the time to establish quality patient relationships and the need to serve multiple roles. The groups did not discuss issues related to specific medical conditions. CONCLUSIONS: Physicians and underserved patients identified communication/respect, cultural issues, and frustration with systems, such as health insurance, transportation, and health delivery systems, as important factors in caring for the underserved. Curricula to teach care of the underserved should include these themes.

STFM's National Clerkship Curriculum: CERA reveals impact, clerkship director needs.

BACKGROUND AND OBJECTIVES: Consistency is needed in family medicine clerkships nationwide. The Society of Teachers of Family Medicine's (STFM) National Clerkship Curriculum (NCC) and supporting NCC website have been developed to address this need. A survey was used to measure these tools' effect and guide future improvements. METHODS: The Council of Academic Family Medicine's (CAFM) Educational Research Alliance (CERA) 2012 survey of clerkship directors (CD) was used to answer two research questions: (1) To what extent are clerkships teaching the minimum core curriculum? and (2) What resources do clerkship directors identify as important in their role? RESULTS: The survey response rate was 66% (88/134). Ninety-two percent of these CDs are aware of the NCC, 74% report having visited the NCC website, and 71% plan to visit it more than once per year in the future. A total of 21.6% strongly agree that their clerkship content matches the NCC. CDs rate the quality of materials on the website as high and place greatest value on materials that can be downloaded and adapted to their clerkships. CONCLUSIONS: STFM's NCC website and materials are familiar to CDs although only one in five state their clerkship curriculum matches the NCC minimum core curriculum. The NCC editorial board needs to better understand why so few teach curriculum that closely matches the minimum core. Continued outreach to CDs can answer this question and improve our ability to support CDs as they incorporate the NCC into family medicine clerkships.