Abstract
Objective
To implement a skills-based faculty development program (FDP) to improve Internal Medicine faculty’s clinical skills and resident teaching about safe opioid prescribing.
Design
An ...FDP for Internal Medicine attendings that included a one-hour didactic presentation followed immediately by an Objective Structured Clinical Examination (OSCE) that focused on assessing and managing opioid misuse risk, opioid treatment outcomes (benefits and harms), and aberrant opioid use behaviors. The evaluation compared pre- and three-months-post-FDP changes in faculty’s safe opioid prescribing knowledge, attitudes, confidence (clinical and teaching), and self-reported resident teaching.
Results
The 25 Internal Medicine faculty participants had a mean of 13 years in clinical practice, including 10 years precepting residents. During the three months post-FDP, faculty treated a mean of 22 patients with chronic pain on long-term opioids and precepted a mean of seven residents caring for patients on long-term opioids. At three months post-FDP, there were significant improvements in correct responses to knowledge questions (68% to 79% P = 0.008), “high-level” confidence in safer opioid prescribing clinical practice (43.5% to 82.6% P = 0.007) and resident teaching (45.8% to 83.3%, P = 0.007), and improvements in alignment of desired attitudes toward safer opioid prescribing. There were nonsignificant increases in self-reported safe opioid prescribing resident teaching.
Conclusions
A skills-based faculty development program that includes a lecture followed by an OSCE can improve Internal Medicine faculty safe opioid prescribing knowledge, attitudes, and clinical and teaching confidence. Improving resident teaching may require additional training in safe opioid prescribing teaching skills.
Objective: To measure the prevalence of chronic obstructive pulmonary disease (COPD) among people aged 40 years or older in Australia.
Design, setting and participants: A cross‐sectional study of ...people in the community aged ≥ 40 years, selected at random using electoral rolls, in six sites chosen to reflect the sociodemographic and geographic diversity of Australia, conducted between 2006 and 2010. Standardised questionnaires were administered by interview. Forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), and the FEV1/FVC ratio were measured by spirometry, before and after bronchodilator administration.
Main outcome measure: Prevalence of COPD, classified according to Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2006 criteria.
Results: Complete data were available for 1620 men (participation rate, 26%) and 1737 women (participation rate, 28%). The prevalence of GOLD Stage II or higher COPD (defined as post‐bronchodilator FEV1/FVC ratio < 0.70 and FEV1 < 80% predicted) was 7.5% (95% CI, 5.7%–9.4%) among people aged ≥ 40 years, and 29.2% (95% CI, 18.1%–40.2%) among those aged ≥ 75 years. Among people aged ≥ 40 years, the prevalence of wheeze in the past 12 months was 30.0% (95% CI, 27.5%–32.5%), and prevalence of shortness of breath when hurrying on the level or climbing a slight hill was 25.2% (95% CI, 22.7%–27.6%).
Conclusions: Symptoms and spirometric evidence of COPD are common among people aged 40 years or older and increase with age. Further research is needed to better understand the diagnosis and management of COPD in Australia, along with continuing efforts to prevent the disease.
Nongeriatricians must acquire skills and knowledge in geriatric medicine to ensure coordinated care of older adults' complex conditions by interspecialty and interprofessional teams. Chief residents ...(CRs) are an ideal target for an educational intervention. This study examined whether the Boston Medical Center Chief Resident Immersion Training (CRIT) in the Care of Older Adults was replicable at diverse medical institutions.
Between 2008 and 2010, 12 institutions in 11 states received funding, technical support, and a common program model. Each implemented 2.5-day CRITs, consisting of a patient case, geriatrics-related lectures, CR leadership sessions, action project planning, and networking time. Site faculty conducted 21 CRITs for 295 CRs representing 28 specialties. CRs completed knowledge pre- and posttests, and self-report baseline and six-month follow-up surveys. Outcome measures were change in pre- and posttest score, and change from baseline to six months in self-reported surveys.
Response rate for CRs was 99% (n = 293) for the pre-post tests and 78% (n = 231) for matchable baseline and follow-up surveys. Participants' knowledge increased from 6.32 to 8.39 (P < .001) averaged from 12 questions. CRs' self-reported ability to apply clinical problem-solving skills to older patients (P < .001), number of geriatrics topics taught (P < .001), frequency of geriatrician consultations (P = .017), confidence in leadership skills (P < .001), and confidence to conduct CR work (P < .001) increased from baseline to follow-up.
CRIT is an innovative way to give nongeriatricians knowledge and skills to treat complex older patients.
Web‐based learning methods are being used increasingly to teach core curriculum in medical school clerkships, but few studies have compared the effectiveness of online methods with that of live ...lectures in teaching the same topics to students. Boston University School of Medicine has implemented an online, case‐based, interactive curriculum using videos and text to teach delirium to fourth‐year medical students during their required 1‐month Geriatrics and Home Medical Care clerkship. A control group of 56 students who received a 1‐hour live delirium lecture only was compared with 111 intervention group students who completed the online delirium curriculum only. Evaluation consisted of a short‐answer test with two cases given as a pre‐ and posttest to both groups. The total possible maximum test score was 34 points, and the lowest possible score was −8 points. Mean pre‐ and posttest scores were 10.5 ± 4.0 and 12.7 ± 4.4, respectively, in the intervention group and 9.9 ± 3.5 and 11.2 ± 4.5, respectively, in the control group. The intervention group had statistically significant improvement between the pre‐ and posttest scores (2.21‐point difference; P < .001), as did the control group (1.36‐point difference; P = .03); the difference in test score improvement between the two groups was not statistically significant. An interactive case‐based online curriculum in delirium is as effective as a live lecture in teaching delirium, although neither of these educational methods alone produces robust increases in knowledge.
Generalist physicians should play a vital role in identifying and managing individuals with substance use but are inadequately trained to do so.
This 5-year (2008-2012) controlled educational study ...assessed whether internal medicine and family medicine chief residents' (CRs) addiction medicine teaching increased by co-training with faculty mentors at a Chief Resident Immersion Training (CRIT) program in addiction medicine. All CRIT CR attendees identified a residency program faculty mentor to support addiction medicine teaching after CRIT through functional mentoring with a focus on developing and implementing an Addiction Medicine Teaching Project ("Teaching Project"). Approximately half of the CRs attended CRIT with their mentor (co-trained) and half without their mentor (solo-trained). Addiction medicine teaching outcomes were compared between groups using 6- and 11-month questionnaires and 4 bimonthly teaching logs. Of co-trained CRs, mentor characteristics that positively influenced addiction medicine teaching outcomes were identified.
One hundred CRs from 74 residency programs attended CRIT from 2008 to 2012; 47 co-trained with their mentors and 53 solo-trained without their mentors. At 6-month follow-up, the co-trained CRs were more likely to meet at least monthly with their mentor (22.7% vs. 9.6%, P < .01) and more likely to identify their mentor as a facilitator for Teaching Project implementation (82.2% vs. 38.5%, P < .01). At 11-month follow-up, a higher percentage of co-trained CRs had completed their Teaching Project (34.0% vs. 15.1%, P < .05). Both CR groups had similarly large increases in other addiction medicine teaching outcomes. Mentors with more experience, including years of teaching, was associated with better CR Teaching Project outcomes.
Co-training generalist chief residents with a faculty mentor appeared to facilitate functional mentoring-driven Teaching Project implementation but did not further increase already high levels of other addiction medicine teaching. Faculty mentors with more years of teaching experience were more effective in facilitating Teaching Project implementation.
Internal medicine residents care for a sizable number of patients with chronic pain. Programs need educational strategies to promote safe opioid prescribing.
To describe a safe opioid prescribing ...education program utilizing an objective structured clinical examination (OSCE) and report the resulting impact on residents' knowledge, confidence, and self-reported practices.
Using a quasi-experimental design, 39 internal medicine residents from an urban academic medical center were assigned to 1 of 4 groups: 1-hour lecture only, lecture followed by immediate OSCE, lecture followed by 4-month delayed OSCE, and control. Safe opioid prescribing knowledge, confidence, and self-reported practices were assessed at baseline and at 8 months.
At 8 months, knowledge, confidence, and self-reported practices improved in the control and in all 3 intervention groups. The immediate OSCE group had the greatest improvements in combined confidence scores within group (0.74, P = .01) compared to controls (0.52, P = .05), using a 5-point scale. This group also had the greatest improvement in self-reported practice changes (1.04, P = .04), while other groups showed nonsignificant improvements-delayed OSCE (0.43, P = .44), lecture only (0.66, P = .24), and control (0.43, P = .19).
Safe opioid prescribing education that includes a lecture immediately followed by an OSCE had an impact on residents' confidence and self-reported practices greater than those for delayed OSCE or lecture only groups. There was no difference in knowledge improvement among the groups. Lecture followed by an OSCE was highly regarded by residents, but required additional resources.
Chief residents (CRs) play a crucial role in training residents and students but may have limited geriatrics training or formal preparation for their CR role. A 2‐day off‐site chief resident ...immersion training (CRIT) addressed these challenges. Objectives were to foster collaboration between disciplines in the management of complex older patients, increase knowledge of geriatrics principles to incorporate into teaching, enhance leadership skills, and help CRs develop an achievable project for implementation in their CR year. Three cohorts totaling 47 trainees and 18 faculty mentors from 13 medical and surgical disciplines participated over 3 successive years. The curriculum, developed and taught by a multidisciplinary team, featured an interactive surgical case, mini‐lectures on geriatrics topics, seminars to enhance teaching and leadership skills, and one‐on‐one mentoring to develop a project in geriatric care or education. Evaluation included pre‐ and postprogram tests and self‐report surveys and two follow‐up surveys or interviews. In 2006 and 2007, scores on a 12‐item objective knowledge test increased significantly (P<.001) from before to immediately after CRIT. Self‐report knowledge and confidence in teaching geriatrics also increased significantly (P<.05) in all formally covered topics. Mean enhancement of CR skills was 4.3 (1=not at all, 5=very much). Eleven months after CRIT, all but five CRs had implemented at least part of their action projects. CRs reported improved care of older patients, better leadership skills, more and better geriatrics teaching, and more collaboration between disciplines. A 2‐day interactive program for CRs can increase institutional capacity regarding geriatrics teaching and care of elderly patients across medical specialties.
Evidence of poor performance in the evaluation and management of common geriatric conditions suggests the need for changing physician behavior in these areas. Traditional lecture‐style continuing ...medical education (CME) has not been shown to be effective. Expert faculty initially trained 60 nonexpert peer educators to conduct small‐group, learner‐centered CME using tool kits on memory loss, incontinence, and depression. Peer educators presented 109 community‐based sessions to 1,309 medical practitioners. Surveys were administered to community participants immediately and 6 months after a session. Evidence of effectiveness included statistically significant increases in self‐reported knowledge, attitudes, and office‐based practices on the target topics at the time of training and at the 6‐month follow‐up (P<.001) and two‐thirds of respondents reporting continued use of three or more tools at 6 months. Participants reported that the interactive presentation aided their understanding of and ability to use the tool kits more than an off‐the‐shelf review (mean rating±standard deviation 4.1±0.71, with 1=not at all and 5=significantly). After the formal evaluation period, additional information about the project dynamics and tool kits was obtained through a small interview sample and an on‐line survey, respectively. Receiving copies of the tool kits was an important factor in enabling educators to offer sessions. Barriers to offering sessions included finding time, an audience, and space. Findings suggest that modest positive changes in practice in relation to common geriatric problems can be achieved through peer‐led, community‐based sessions using principles of knowledge translation and evidence‐based tool kits with materials for providers and patients.
Many community‐based internists and family physicians lack familiarity with geriatrics knowledge and best practices, but they face overwhelming fiscal and time barriers to expanding their skills and ...improving their behavior in the care of older people. Traditional lecture‐and‐slide‐show continuing medical education (CME) programs have been shown to be relatively ineffective in changing this target group's practice. The challenge for geriatrics educators, then, is to devise CME programs that are highly accessible to practicing physicians, that will have an immediate and significant effect on practitioners' behavior, and that are financially viable. Studies of CME have shown that the most effective programs for knowledge translation in these circumstances involve what is known as active‐mode learning, which relies on interactive, targeted, and multifaceted techniques. A systematic literature review, supplemented by structured interviews, was performed to inventory active‐mode learning techniques for geriatrics knowledge and skills in the United States. Thirteen published articles met the criteria, and leaders of 28 active‐mode CME programs were interviewed. This systematic review indicates that there is a substantial experience in geriatrics training for community‐based physicians, much of which is unpublished and incompletely evaluated. It appears that the most effective methods to change behaviors involved multiple educational efforts such as written materials or toolkits combined with feedback and strong communication channels between instructors and learners.
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