Design of a Multicenter Randomized Controlled Trial comparing the effectiveness of shared decision making versus motivational interviewing plus cognitive behavioral therapy for voluntary opioid tapering: The INSPIRE study protocol.

BACKGROUND: This paper describes the design and protocol of a pragmatic, randomized trial to evaluate the comparative effectiveness of shared decision making versus motivational interviewing plus cognitive behavioral therapy for chronic pain for the voluntary tapering of opioid dose in adults with chronic noncancer pain. Integrated Services for Pain: Interventions to Reduce Pain Effectively (INSPIRE) is a multicenter, randomized trial conducted at three academic health centers in the southeastern United States. Participants are adults receiving long-term opioid therapy of at least 20 morphine milligram equivalents daily for chronic noncancer pain. METHODS: Participants were randomized to either the shared decision-making intervention or the motivational interviewing session and cognitive behavioral therapy for chronic pain intervention. All participants also received guideline-concordant care supporting opioid pharmacotherapy. The primary outcome was change from baseline in average daily prescribed opioid dose at 12 months, using prescribing data from electronic health records. Secondary outcomes were Patient-Reported Outcomes Measurement Information System Pain Interference and Physical Function at 12 months. CONCLUSION: This trial evaluates the comparative effectiveness of shared decision making versus motivational interviewing plus cognitive behavioral therapy for chronic pain for the voluntary tapering of opioid dose in adults with chronic noncancer pain. Results from this study can guide clinicians, researchers, and policymakers as they seek to reduce opioid prescribing and improve management of chronic pain. CLINICAL TRIALS REGISTRATION: ClinicalTrials.gov Identifier: NCT03454555 (https://clinicaltrials.gov/ct2/show/record/NCT03454555). Participant enrollment began on June 26, 2019.

Online Core Curriculum and Mastery (OCCAM): A Behavioral Neurology & Neuropsychiatry (BNNP) Curricular Needs Assessment.

Behavioral neurology & neuropsychiatry (BNNP) fellowships are accredited by the United Council for Neurologic Subspecialties (UCNS). Programs cover the UCNS-recommended topics differently. A curriculum accessible to all fellowships would standardize education and identify gaps in topics that are less well covered across programs. The purpose of the present needs assessment was to inform the development of the Online Core Curriculum and Mastery: BNNP (OCCAM-BNNP), a website for all UCNS-accredited BNNP programs. Program directors and fellows were surveyed to learn how well topics are covered and identify educational gaps, or specific topics on the UCNS website that are less well represented among programs. Thirty-seven fellowship program directors listed on the UCNS website were invited to take the survey and forward it to both current fellows (graduating in 2021) and recent graduates (graduated from 2015 to 2020). There were 29 responses from 37 programs. Of the 34 topics that respondents rated on a 1-5 Likert scale (from "not covered" to "completely covered"), 15 of 34 (44%) were identified as having >40% of responses as mostly "not covered," "incompletely covered," or "partially covered." Ninety-seven percent of respondents affirmed that it would be useful to have a free web-based resource for BNNP education. Slightly under one-half of all BNNP topics were not well covered. A survey was undertaken to identify and fill the educational gaps indicated by fellowship directors and fellows, and the OCCAM-BNNP website was developed as a repository for relevant content, providing a resource that many BNNP clinicians would find useful.

Five Years Later: Impact of a Focused Women in Radiology Program.

PURPOSE: Women are underrepresented in radiology and experience barriers to professional growth that can affect job satisfaction and career advancement. The authors hypothesized that a structured, intentional Women in Radiology (WiR) program would increase women faculty members' perceptions of workplace gender equity, satisfaction with pace of professional advancement, interest in research and teaching, and perceptions of work-life balance and mentorship opportunities. METHODS: Components and structure of a sustainable WiR program are described in detail. Baseline and summative 5-year surveys of women faculty members in the department were distributed. The primary outcome measure was perception of equitable access to professional development opportunities for women. The authors also assessed the impact of the WiR program on creating a departmental culture shift to improve career advancement for women. Secondary outcomes included WiR's impact on women's satisfaction with pace of professional advancement, mentorship opportunities, work-life balance, and interest in research and teaching. RESULTS: Compared with 5 years prior, more women faculty members now believe that there is equitable access to career advancement opportunities and that the formal WiR program has contributed to a positive culture shift in the department. Significant gains in women faculty members' satisfaction with pace of their professional advancement were demonstrated. During the study period, more women developed interest in teaching and research, served as mentors, and perceived improvements in work-life balance compared with baseline. CONCLUSIONS: A structured, intentional WiR program can contribute to improved workplace gender equity, career satisfaction for women, and a positive departmental culture shift to support the needs of women in radiology.

Influences on and Characteristics of the Professional Identity Formation of Clinician Educators: A Qualitative Analysis.

PURPOSE: Professional identity formation is the process of internalizing the ideals, values, and beliefs of a profession. In recent years, research on clinician-educator (CE) identity formation has expanded, yet gaps exist in understanding initial influences on an educator identity, sustainment throughout a career, and development of successful pathways for early CEs. This study explored the initial influences on and characteristics of the professional identity formation of CEs in an age-diverse, multispecialty population in the United States. METHOD: This was a cross-sectional qualitative study of a purposive sample of medical educators at 6 institutions across the United States between 2018 and 2019. Focus groups were conducted to obtain participants' perspectives on their career choice and subsequent formation of their professional identity as CEs. The authors used a thematic analysis of focus group data to identify themes and domains through an iterative process. RESULTS: Twelve focus groups were conducted with a total of 93 participants. Responses were categorized into 5 domains: community supportive of medical education, culture of institution and training, personal characteristics, facilitators, and professionalization of medical education. Themes highlighted the importance of role models and mentors, an affinity and aptitude for teaching and education, specific facilitators for entry into a career in medical education, the evolution from a layperson, importance of formalized training programs, and a supportive academic community. CONCLUSIONS: Clinicians experienced a variety of factors that influenced their initial career choice in medical education and subsequent professional identity formation as a CE. This study confirms and expands the current understanding of this process in an age-diverse, multispecialty population of CEs. Educators and administrators designing career development programs across the continuum of medical education should consider these aspects as they mentor and support their learners and faculty.

A Professional Development Course Improves Unprofessional Physician Behavior.

BACKGROUND: In 2008 The Joint Commission issued a Sentinel Event Alert that further defined "behaviors that undermine a culture of safety," stating that "intimidating and disruptive behaviors" can result in medical errors that affect patient care and safety. The American College of Physician Executives found that more than 95% of respondents encountered "disturbing . . . and potentially dangerous" behaviors on a regular basis. The purpose of this study is to evaluate the effectiveness of a professional development program on unprofessional physician behaviors using the B29™, a reliable and valid tool to assess workplace behaviors. METHODS: A pre-post study design was used to measure changes in physicians' unprofessional behaviors using the B29, a 35-item, Web-based survey. The survey is completed as a 360° assessment by peers, colleagues, administrators, and staff, and the physician completes a self-assessment. In most cases, the survey is voluntary. Those who completed both a precourse and a postcourse survey made up a convenience sample or subset of the larger number of physicians who completed the course. RESULTS: Twenty-four of 28 physicians in the study experienced an improvement in professional behavior, demonstrated as a decrease in the number of lowest-rated items. The mean decrease for all 28 physicians was 51.1%. Lowest-rated items improved an average of 53.5% overall. T-scores increased (also improved) for 24 of 28 physicians over the six-month period. CONCLUSION: Unprofessional behavior by physicians, as observed and reported by their peers and colleagues, can be positively modified by a relatively brief education program focused on teaching professionalism.

The Relationship Between Institution-Affiliated Childcare and Employee Stress.

OBJECTIVE: To evaluate the relationship between utilization of institution-affiliated childcare and employee stress among parents working at a large, academic medical center. METHODS: Cross-sectional analysis of the relationship between institution-affiliated childcare and employee stress. Survey questions asked about personal stress related to job, relationship with spouse, parental responsibilities, childcare, finances, and personal health. RESULTS: 558 (68%) respondents were predominantly women (76.9%). Fifty-four percent had non-institution-affiliated childcare and 45% had institution-affiliated childcare. Use of institution-affiliated childcare was associated with less overall stress (-4.86 [95% confidence interval -8.01, -1.72], P = 0.003), and less stress related to finances, childcare, and personal health. Differences between groups related to job, relationship with spouse, or parental responsibilities were not statistically significant. CONCLUSIONS: This study demonstrated an association between institution-affiliated childcare and lower stress, highlighting the centrality of employer-affiliated childcare to employees' stress.

Reshaping the residency environment to enhance education and mitigate burnout.

Burnout remains a widespread issue in graduate medical education, with current trends to mitigate burnout shifting toward institutional systematic interventions as opposed to personal individual interventions. In this article, we propose utilizing Knowle's adult learning theory in conjunction with Maslach's organizational context for burnout to implement systemic changes within the postgraduate training environment that we posit would both optimize the learning experience and reduce the incidence of burnout.

Identification of training opportunities in medical education for academic faculty.

Introduction: Clinician-educators are responsible for providing education to trainees in medical centers. There is no clear overview of what opportunities exist for training clinician-educators in medical education related skills and techniques. Methods: We conducted a systematic review of multiple websites and a medical educator listserve to identify medical education training opportunities for clinician-educators. We included certificate level programs or programs with comparable recognition and excluded masters programs, programs specific to one medical specialty or institution, and brief modules/sessions. We categorized results by training/focus area(s) and program details relevant for faculty. Results: We identified 53 programs. Most focus on general medical education skills (N = 19, 36%), leadership (N = 18, 34%), or learner assessment (N = 16, 30%). Fourteen programs (26%) were exclusively online, 27 (56%) exclusively in-person, and 12 (23%) require in-person and distance components. Time requirements for completion vary greatly, ranging from 1 day to 3 years, as did program costs, ranging from $327 to $15,000. Conclusions: Although training programs in medical education for clinical faculty exist, most focus on general medical education, leadership, and assessment. More programs focused on other topics, such as simulation or educational research, may be needed. Future investigations to understand the needs of this population would be valuable.

A Leadership Intervention to Further the Training of Female Faculty (LIFT-OFF) in Radiology.

RATIONALE AND OBJECTIVES: Women are under-represented in the field of radiology, occupy a minority of leadership positions, and, at our institution, have not achieved the same level of academic success as their male counterparts. Consequently, the authors designed, implemented, and evaluated the Leadership Intervention to Further the Training of Female Faculty (LIFT-OFF) program to (1) improve access to opportunities for women's faculty development and advancement, and (2) improve clarification of expectations about the role and path of advancement. MATERIALS AND METHODS: LIFT-OFF was developed based on the results of a needs assessment survey. The results generated 14 priority topics, which served as the basis for educational modules conducted by expert speakers. Module effectiveness was assessed with pre- and postsurveys to elicit participant knowledge about the targeted subject matter. A formative program evaluation was performed at the completion of year 1 of 2 to assess outcomes and impacts to date. RESULTS: Seventeen of 55 (31%) educational module post-survey questions demonstrated a statistically significant (P < 0.05) increase in "yes" responses, indicating an improved understanding of targeted information. At year 1, 75% of the participants indicated that the program improved access to faculty development opportunities and 62% reported improved access to career advancement opportunities. Satisfaction with pace of professional advancement increased from 25% to 46% for junior women faculty (P = 0.046). CONCLUSIONS: Faculty development programs such as LIFT-OFF can provide career development opportunities and executive skills necessary for women to achieve academic career success and assume leadership positions.

Entrustable professional activities (EPAs) for teachers in medical education: Has the time come?

On a daily basis, patients put their trust in the healthcare system for safe and high-quality healthcare. However, what evidence do we have as an educational community that our supervising faculty members are competent to fulfill this responsibility? Few, if any, requirements exist for faculty members to have continuous professional development in the field of medical education. Many faculty "love to teach", however, this love of teaching does not make them competent to teach or assess the competence of trainees whom they supervise. Faculty members who have a significant role as a teacher in the clinical setting should be assessed with regards to their baseline competence in applicable teaching EPAs. When competence is reached, an entrustment decision can be made. Once proficient or expert, a statement of awarded responsibility (STAR) may be granted. The time has come to reach beyond the "standards" of the old adage "see one, do one, teach one" in medical education. In this personal view, the authors outline an argument for and list the potential benefits for teachers, learners, and patients when we assess clinical teachers using EPAs within a competency-based medical education framework.

Misprescribing controlled substances: An evaluation of a professional development program.

BACKGROUND: Controlled prescription drug (CPD) abuse has reached epidemic proportions in the United States. Most physicians attending a 3-day continuing medical education (CME) professional development program (PDP) lack training in identifying risk and in managing patients who misuse CPDs. To address this issue, the authors conducted an evaluation of a PDP that trains physicians on proper prescribing, identifying substance abuse, utilizing screening, brief intervention, and referral to treatment (SBIRT), and implementing motivational interviewing (MI). METHODS: The authors conducted a program evaluation to assess the efficacy and impact of the PDP on physicians' knowledge and prescribing behaviors. RESULTS: Participants (N = 174) were typically middle-aged (average age of 53 years), male (89%), and physicians (82%) and other health care professionals (18%). Many physicians practice in solo primary care settings (46%). Course evaluations were completed by n = 155 (89%) participants who rated the course and presenters highly (mean 4.8/5 respectively). Physicians' knowledge scores on pre/post assessments increased significantly: pretest (M = 58.7, SD = 13.12) and posttest (M = 78.28, SD = 9.83) (t(173) = 20.06, P ≤ .0001, 95% confidence interval, CI: [-21.51, -17.65]). Almost half of the participants, n = 83/174 (48%), completed the follow-up survey, and 93% agreed/strongly agreed (A/SA) they made professional practice changes. Of participants practicing with an active DEA (Drug Enforcement Administration) registration (n = 57), most agreed/strongly agreed they implemented changes to align their practices with current guidelines (89%), used CPD more appropriately (87%), implemented office policies on prescribing (81%), identified and referred more substance abuse patients to treatment (80%), shared new information/experience from course with other 25 health professionals (93%), and felt the course positively impacted their behaviors personally and professionally (90% and 96%, respectively). CONCLUSIONS: This is the first known study evaluating a PDP in this population. Results demonstrated participant satisfaction and improvement in prescribers' knowledge and self-reported prescribing behaviors. However, further study is needed to assess actual clinical practice changes, direct impact on patient outcomes, and rates of recidivism.

Twelve tips for developing, implementing, and sustaining medical education fellowship programs: Building on new trends and solid foundations.

Medical education fellowship programs (MEFPs) are a form of faculty development contributing to an organization's educational mission and participants' career development. Building an MEFP requires a systematic design, implementation, and evaluation approach which aligns institutional and individual faculty goals. Implementing an MEFP requires a team of committed individuals who provide expertise, guidance, and mentoring. Qualified MEFP directors should utilize instructional methods that promote individual and institutional short and long term growth. Directors must balance the use of traditional design, implementation, and evaluation methodologies with advancing trends that may support or threaten the acceptability and sustainability of the program. Drawing on the expertise of 28 MEFP directors, we provide twelve tips as a guide to those implementing, sustaining, and/or growing a successful MEFP whose value is demonstrated by its impacts on participants, learners, patients, teaching faculty, institutions, the greater medical education community, and the population's health.

Rheumatologic skills development: what are the needs of internal medicine residents?

Given the burden of rheumatic disease in our society and the anticipated future shortage of rheumatologists, all internal medicine (IM) residencies need to train internists who are capable of caring for patients with rheumatic diseases. The objective of this study was to perform a targeted needs assessment of the self-confidence of IM residents in the evaluation and care of patients with rheumatologic diseases. A 16-item, web-based, self-assessed confidence survey tool was administered to participating post graduate year (PGY)1 (N = 83) and PGY3 (N = 37) residents. The categories of questions included self-confidence in performing a rheumatologic history and exam, performing common rheumatologic procedures, ordering and interpreting rheumatologic laboratory tests, and caring for patients with common rheumatologic diseases. Resident demographics, prior rheumatology exposure, and career plans were also queried. PGY3 residents had higher self-assessed confidence than PGY1 residents in all categories. Self-assessed confidence in joint procedures was consistently low in both groups and when compared to other categories. Prior exposure to a rheumatology course or elective was not consistently associated with higher self-assessed confidence ratings across all categories. PGY3 residents showed less interest in rheumatology as a career than PGY1 residents, although the interest in the topic of rheumatology was not statistically different. Our needs assessment shows a low level of self-assessed confidence in rheumatology knowledge and skills among IM residents. Despite improvement with PGY year of training, self-assessed confidence remains low. To improve resident's skills and self-confidence in rheumatology, more curricular innovations are needed. Such innovations should be assessed for overall effectiveness.

Spanning a Decade of Physician Boundary Violations: Are We Improving?

Sexual boundary violations can negatively impact the culture of safety within a medical practice or healthcare institution and severely compromise the covenant of care and physician objectivity. Lack of education and training is one factor associated with physician misconduct that leads to high financial and personal cost. This paper presents a follow-up study of physicians referred to a professional development course in 2001 and presents demographic data from 2001 to present. The paper focuses on the education and remediation progress regarding sexual misconduct by physicians.

Faculty Development on Clinical Teaching Skills: An Effective Model for the Busy Clinician.

INTRODUCTION: The authors developed and evaluated a faculty development program on clinical teaching skills to address barriers to participation and to impact teaching behaviors. METHODS: Four one-hour workshops were implemented over five months. Evaluation included participant satisfaction and pre/post self-assessment. Pre/post faculty teaching ratings by trainees were compared. RESULTS: A total of 82% of faculty (N = 41) attended. Participants rated workshops highly (mean, 4.43/5.00). Self-assessment of skills and comfort with teaching activities improved. A total of 59% of residents and 40% of fellows felt that teaching received from participating faculty was highly effective. The majority observed targeted teaching behaviors by the faculty. Teaching ratings improved after the workshops (P = 0.042). CONCLUSION: Our series of short workshops during a standing conference time was associated with increased self-assessed skill and comfort and an increase in faculty ratings on teaching evaluations. Effective faculty development programs can be implemented in flexible formats and overcome common barriers to participation.

Searching for answers: proper prescribing of controlled prescription drugs.

Prescription drug abuse is increasing at alarming rates in this country. Most often drugs are obtained through relatives or friends. An important step in addressing this problem is educating healthcare providers in the proper prescribing of scheduled drugs. Physicians and other healthcare workers receive little training in proper screening for substance abuse, proper prescribing of scheduled drugs, and referral for those needing treatment. Continuing medical education is one venue for addressing this problem. However, screening, brief intervention and referral for treatment (SBIRT) should be taught in medical school and residency.

Using standardized patients in continuing medical education courses on proper prescribing of controlled substances.

Controlled prescription drug (CPD) abuse is an increasing threat to patient safety and health care providers (HCPs) are not adequately prepared nor do they routinely employ proper screening techniques. Using standardized patients (SPs) as an instructional strategy, the trained physicians on proper prescribing practices and SBIRT (Screening, Brief Intervention, and Referral to Treatment) in a continuing medical education (CME) course. The authors compared two physician cohorts receiving standard CME course (control) versus CME plus SP practice. They measured knowledge and attitudes in all participants and skills and perceived competence in the SP group only. Knowledge and attitudes improved significantly for both groups. Screening behaviors for CPD use also improved. Participants overestimated their performance but increased their use of SBIRT with practice. The SP comfort levels with physician's competence improved after 2 practice sessions. Standardized patients can be an effective teaching tool in CME courses. Impact on knowledge or attitudes did not increase significantly over controls.