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.

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.

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.

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.

Relationship between smoking and obesity among women.

OBJECTIVES: To examine the relationship between smoking and weight status in adult women and whether this association differed by race. METHODS: The study sample consisted of 22,949 African American and 7831 white women enrolled in the Southern Community Cohort Study from 2002 to 2006. RESULTS: Both African American and white current smokers had decreased odds of being overweight or obese compared to normal-weight nonsmokers, and the inverse trends between current smoking and BMI held for both groups. CONCLUSION: A strong relationship exists between smoking and weight status, with patterns nearly identical for African Americans and white women.

Rethinking CME: an imperative for academic medicine and faculty development.

To help address the clinical care gap, a working group discussed the future of faculty development in academic medicine, explored problems within the large, current enterprise devoted to continuing medical education (CME), and described four domains core to its revitalization and reformation. These domains are (1) preparing and supporting an engaged clinician-learner, (2) improving the quality of knowledge or evidence shared, (3) enhancing the means by which to disseminate and implement that knowledge and evidence, and (4) reforming the patient, health care, and regulatory systems in and for which the process of CME exists. Reshaping these domains requires the consideration of a more seamless, evidence-based, and patient-oriented continuum of medical education. Revitalizing CME also requires the full engagement of the academic medical community and its faculty. To achieve the goal of creating a new, more effective, seamless process of CME, the working group recommended an active faculty development process to develop strong clinician-learners, strong involvement of academic health center leaders, the development of an educational home for clinician-learners, and a meaningful national conversation on the subject of CME.

A plan for identification, treatment, and remediation of disruptive behaviors in physicians.

Physicians exhibiting a pattern of disruptive conduct represent a small portion of all healthcare professionals. Available evidence demonstrates, however, that their behaviors can result in increased workplace stress; contribute to poor workplace environments; contribute to dysfunctional teams; reduce quality of care for patients and families; and increase risk of litigation for hospitals and institutions. Our experience at Vanderbilt reveals that both internal and external factors play a role in a physician's behavior and ability to cope with workplace stresses. We have gained valuable insight into various means of indentifying, assessing, treating, and remediating physicians exhibiting unprofessional behavior. The vast majority of healthcare team members conduct themselves professionally and without complaint. This paper will demonstrate how to address those rare individuals who exhibit disruptive and/or unprofessional behavior.

Chronic pain in patients with substance abuse disorder: general guidelines and an approach to treatment.

Treating pain may be difficult in patients with a coexisting substance abuse disorder. Opioids can be used successfully to control pain in such a patient population, but the physician must have a general understanding of addictive behavior and early signs of abuse. The challenge is not in treating pain, but identifying true pain from drug-seeking behaviors. Furthermore, several myths of opioid usage, such as iatrogenic addiction and risk of disciplinary action, may be unfounded. General guidelines and open communication between patient and physician may aid in controlling pain. With better understanding and a systematic treatment approach, patients with substance abuse disorders can receive adequate symptomatic pain relief.

Residents-as-teachers programs in psychiatry: a systematic review.

OBJECTIVES: Because psychiatry residents have important roles as teachers and significant opportunities to contribute to medical student education, we set out to: identify all randomized control trials (RCT) for residents' teaching skills programs in psychiatry and to identify the efficacy of those interventions for improving teaching skills; identify the strengths and weaknesses of the available studies across medical disciplines; and identify currently available methods for enhancing residents' teaching skills for residents training in psychiatry. METHODS: The published English-language literature was searched using PubMed, Social Sciences Index, and PsycINFO databases, with key search words including: residents, teaching skills, residents as teachers, psychiatry, and assessments. Both RCT and controlled, nonrandomized trials of residents' teaching programs directed to enhance residents' teaching skills were selected and critically appraised. RESULTS: Of 13 trials identified and reviewed, most included residents in internal medicine. Only one included psychiatry residents and assessed their ability to teach interviewing skills to medical students. Along with other studies, this study demonstrated improvement in residents' teaching skills. Overall, interventions and outcome measures were heterogeneous while the quality of methodologies varied. Five studies were of higher quality, representing examples of quality educational research. Several described group differences, blinding, good follow-up, and use of valid, reliable tools. CONCLUSIONS: Only one trial exists that incorporated psychiatry residents. Significant opportunity to advance educational research in this field exists. Psychiatry residency program directors should incorporate high-quality methodologies and can benefit from the findings of trials in other disciplines.

The emergence of academies of educational excellence: a survey of U.S. medical schools.

PURPOSE: To identify existing organizations that recognize faculty members' excellence as educators (Academies) in the United States, and describe the organizations' characteristics. METHOD: A 31-item questionnaire inquiring about Academies or equivalent programs was sent to deans of medical education at all 125 U.S. medical schools in February of 2003. Variables examined were general Academy characteristics such as membership selection criteria, goals, benefits of membership, and budget, as well as, estimates of prestige of membership and influence on recruiting new and current faculty to educational activities. RESULTS: Twenty of 97 (21%) respondents reported an implemented Academy or equivalent program (eight begun prior to 2000 and 11 subsequently). Most Academies (75%) did not "cap" membership size, and most (65%) offered lifetime membership. Budgets ranged from 0 dollars to more than 100,000 dollars per year. Full-time faculty status (100%) and involvement in direct undergraduate teaching (95%) affected eligibility the most. Nominations for membership most often came from department or section chairs (89%) and from peers (74%), and learners were involved in the final selection process at 18 of the Academies. Benefits of membership included networking/collaboration, school-wide recognition, and mentoring for educational skills development. The benefit of protected time was offered at only three institutions and was associated with having a larger budget. Respondents believe Academies positively influence faculty participation in educational activities. CONCLUSIONS: Academies are formal organizations recognizing faculty contributions to medical education, and they are increasing in number. They offer important benefits to faculty members and the educational mission of an academic medical center.