Communicating value to patients-a high-value care communication skills curriculum.

INTRODUCTION: With rising health care costs in the United States, trainees will be increasingly challenged in discussing testing stewardship with patients. OBJECTIVE: We piloted a high-value care (HVC) communication skills curriculum utilizing the Four Habits Model for communication. We hoped residents would 1) learn to apply the Four Habits communication model to HVC discussions with standardized patients (SP) and 2) improve value-based communication skills through training in a high-intensity curriculum with feedback from trained faculty facilitators and peers. METHODS: Thirty interns at the University of Minnesota were randomized to a standard HVC communication SP encounter (n = 15) or a high-intensity HVC communication skills curriculum (n = 15). The high-intensity curriculum included video and audio-recorded SP encounters followed by facilitated small group discussions/feedback. Experiences were reported in a post-intervention survey; communication skills were assessed with the CARE empathy scale. RESULTS: 70% (21/30) of interns (57% high intensity, 43% standard) responded to the survey. In total, 88% of high intensity v. 44% of standard interns agreed/strongly agreed that the curriculum was valuable for their communication skills. High-intensity interns were more likely to report that feedback was valuable with subsequent incorporation of feedback into future patient encounters. High-intensity participants also reported higher levels of interest in future HVC curricula (55% vs 22%). CONCLUSION: There was no difference in overall performance on the CARE empathy scale. Our HVC high-intensity skills curriculum was well received by interns and provided opportunities to practice structured conversations and debrief around testing stewardship.

Changing residents' beliefs and concerns about treating chronic noncancer pain with opioids: evaluation of a pilot workshop.

OBJECTIVE: To determine if a pilot phase workshop influenced residents' beliefs and concerns about using opioids for chronic noncancer pain. DESIGN: Pre- and post-survey questionnaire. SETTING: University residency program. PARTICIPANTS: Seventy-two Medicine and Medicine-Pediatrics residents. INTERVENTIONS: Participation in a 4-hour workshop based on adult learning theory. OUTCOME MEASURES: Residents' pre- and post-workshop concerns, feelings, and beliefs about the efficacy and safety of opioids for chronic noncancer pain (low back pain), and barriers to prescribing them (paired t-tests). RESULTS: On a scale of 1 = least to 10 = most, residents' concerns about addiction risk from opioids in patients with chronic noncancer pain dropped significantly (P < 0.001) after the workshop (Pre 6.02 to Post 3.07). Similar changes were observed regarding concerns about abuse (5.61 to 3.92), side effects (4.88 to 2.88), limiting use of other treatments (5.41 to 3.60), sanctioning (State Board; 4.27 to 3.71; Legal 4.22 to 3.43), and drawing criticism from attending staff (4.50 to 2.77), with P < 0.001 for each. Their beliefs about efficacy and safety of opioids for chronic noncancer pain increased (Pre 4.96 to Post 7.40), and they were more comfortable prescribing them (4.30 to 6.82), with P < 0.001 for both. After the workshop, nine of 13 barriers to prescribing opioids for chronic noncancer pain were significantly (P < 0.05) lower. CONCLUSION: Residents' beliefs and concerns about using opioids for chronic noncancer pain changed after participating in a 4-hour interactive workshop.

Medical residents' beliefs and concerns about using opioids to treat chronic cancer and noncancer pain: a pilot study.

This study assessed and compared residents' beliefs and concerns about using opioids for treating pain in patients with cancer and noncancer low back pain (NLBP). Participants included 72 Internal Medicine and Medicine-Pediatrics residents who completed a survey questionnaire. Based on a scale of 0 = "No concern" to 10 = "Very concerned," residents expressed greater concern that treating NLBP with opioids, compared with cancer-related pain, causes addiction (6.01 vs 1.15), abuse (5.57 vs 1.39), and side effects (4.76 vs 2.87); limits other treatments (5.36 vs 1.30); draws criticism from faculty (4.33 vs 0.88); or risks sanctioning (state board 4.12 vs 1.12, legal 4.06 vs 1.17); p < 0.001 for each (paired t-tests). They had more comfort (8.94 vs 4.31) and more empathy (9.09 vs 6.79) using opioids to treat for cancer pain than NLBP and would give whatever doses necessary for pain control (8.41 vs 3.66); p < 0.001 for each. Our findings show that residents are far more concerned about using opioids to treat NLBP than cancer-related pain.

Evaluation of a worksheet to structure teaching and learning outpatient internal medicine.

The Worksheet for Ambulatory Medicine (WAM) is an educational tool designed to enhance teaching and learning outpatient internal medicine. It was developed to identify student learning needs, focus teaching, and structure educational and patient care activities in a clinic setting. The purpose of the study was to assess the feasibility and educational value of using the WAM with medical students and preceptors. Sixty-five third- and fourth-year medical students and 12 supervising faculty at two university-based general medicine outpatient clinics used the WAM during required internal medicine clerkships. Students and faculty completed written evaluations. Results are reported as percentages of respondents agreeing or disagreeing with a variety of statements, and mean rating scores for several questions designed to assess the feasibility and educational value of using the worksheet. Student response rate was 89%; 83% found the WAM easy to use; 65% found it too structured. Half said the worksheet helped diagnostic decision making and note writing, and two-thirds thought it promoted careful thinking about differential diagnosis and aided in identifying learning issues. Some 56% said using the WAM motivated outside reading. Most students found it helpful for identifying patient agendas and focusing case presentations (61% and 67, respectively). Only 36% said the WAM helped with time management. Most preceptors thought the WAM helped identify earning issues, focus case presentations and clarify student expectations. There was less agreement among preceptors that it allowed them to demonstrate clinical reasoning or provide students with more autonomy in decision making. Nearly half the preceptors did not find it helpful with time management. Both students and preceptors rated the overall value and usefulness of the WAM as good to very good, and a majority recommended that others use it. Using the Worksheet for Ambulatory Medicine was feasible and educationally valuable for many third- and fourth-year medical students and their preceptor in a required ambulatory internal medicine clerkship.

A communication assessment and skill-building exercise (CASE) for first-year residents.

OBJECTIVE: Good communication skills are essential for residents entering postgraduate education programs. However, these skills vary widely among medical school graduates. This pilot program was designed to create opportunities for (1) teaching essential interviewing and communication skills to trainees at the beginning of residency, (2) assessing resident skills and confidence with specific types of interview situations, (3) developing faculty teaching and assessment skills, (4) encouraging collegial interaction between faculty and new trainees, and (5) guiding residency curricular development. DESCRIPTION: During residency orientation, all first-year internal medicine residents (n = 26) at the University of Minnesota participated in the communication assessment and skill-building exercise (CASE). CASE consisted of four ten-minute stations in which residents demonstrated their communication skills in encounters with standardized patients (SPs) while faculty members observed for specific skills. Faculty and SPs were oriented to the educational purposes and goals of their stations, and received instructions on methods of providing feedback to residents. With each station, residents were provided one and a half minutes of direct feedback by the faculty observer and the SP. The residents were asked to deal with an angry family member, to counsel for smoking cessation, to set a patient-encounter agenda, and to deliver bad news. A resident's performance was analyzed for each station, and individual profiles were created. All residents and faculty completed evaluations of the exercise, assessing the benefits and areas for improvement. DISCUSSION: Evaluations and feedback from residents and faculty showed that most of our objectives were accomplished. Residents reported learning important skills, receiving valuable feedback, and increasing their confidence in dealing with certain types of stressful communication situations in residency. The activity was also perceived as an excellent way to meet and interact with faculty. Evaluators found the experience rewarding, an effective method for assessing and teaching clinical skills, a faculty development experience for themselves in learning about structured practical skills exercises, and a good way to meet new interns. The residency program director found individual resident performance profiles valuable for identifying learning issues and for guiding curricular development. Time constraints were the most frequently cited area for improvement. The exercise became feasible by collaborating with the medical school Office of Education-Educational Development and Research, whose mission is to collaborate with faculty across the continuum of medical education to improve the quality of instruction and evaluation. The residency program saved considerable time, effort, and expense by using portions of the medical school's existing student skills-assessment programs and by using chief residents and faculty as evaluators. We plan to use CASE next year with a wider variety of physician-patient scenarios for interns, and to expand the program to include beginning second- and third-year residents. Also, since this type of exercise creates powerful feedback and assessment opportunities for instructors and course directors, and because feedback was so favorable from evaluators, we will encourage participation in CASE as part of our faculty educational development program.