Tell Me Your Story: Experiential learning using in-home interviews of healthy older adults.

PURPOSE: To create a curriculum innovation for early preclinical medical students to explore personal perspectives by listening to and learning from the lived experience of community-living older adults. METHOD: Tell Me Your Story (TMYS) paired first-year medical students (MS1s) with community-dwelling older adult partners (OAPs) residing in the independent living portion of a continuing care retirement community (CCRC) for a half-day educational experience. MS1s conducted 1-hour semi-structured interviews with their OAP and then formed small groups with geriatric faculty members to explore experiences and views that were either reinforced or challenged. The authors evaluated the effectiveness of this exercise using post-activity surveys. A mixed-methods analysis of 7 years of data (2013-2019) was conducted. RESULTS: TMYS had 1251 MS1 participants from 2013 to 2019. Students completed 1052 surveys for a response rate of 84%. During the semi-structured interview with OAP, the frequency of issues discussed included relationships (94%), professionalism/art of medicine (91%), healthcare accessibility (83%), death/dying/grieving/loss (72%), nutrition (69%), ethics (64%), and cultural competence (61%). Exactly 97% (n = 1023) responded that the overall organization was "good, very good or excellent." The most prominent themes identified by student responses highlighted person-centered care, patient perspective, life experience/personal stories, and doctor-patient relationship. Fifty-three faculty members completed the post-program survey. Exactly 100% (53/53) rated the quality of this exercise as an educational experience high. CONCLUSION: TMYS was highly valued by students and provided an important experiential learning activity in preclinical medical education. Themes related to person-centered care emerged from the intervention.

The Virtual Patient and Family Advisory Council in the COVID-19 Era.

BACKGROUND: In 2016, we launched our first Patient and Family Advisory Council (PFAC) as a means of collaborating with our patients and families to improve care. Using an Internet-based remote meeting technology, we transitioned to a virtual platform in April. METHODS: We have conducted 12 PFAC meetings across 4 sites to date. Virtual PFAC meeting topics over the past few months include communication about the coronavirus, community resources needed by patients during the pandemic, telehealth visit troubleshooting, current office policy, and changing work flow. A convenience sample of advisors generated qualitative responses on the transition from in-person meetings to a virtual platform. RESULTS: Attendance increased as we transitioned to a virtual platform from 13.2 advisors to 14.7 advisors. Advisors affirm the value of a PFAC and importance of patient engagement, especially during this pandemic. Patient advisors confirm the role of patient voice in pandemic-induced practice changes. DISCUSSION: The transition of our PFACs to a virtual platform continues to generate critically important partnerships between patients and providers. In this time of health care uncertainty and stress for patients, providers, and staff, this partnership remains our most valuable asset. CONCLUSION: Patient voice provides reliable and relevant information for practices through virtual PFAC meetings.

Evaluation of an interprofessional naloxone didactic and skills session with medical residents and physician assistant learners.

BACKGROUND: The CDC has reported 399,230 opioid-related deaths from 1999-2017. In 2018, the US surgeon general issued a public health advisory, advising all Americans to carry naloxone. Studies show that enhanced naloxone access directly reduces death from opioid overdose. Despite this, health care professional learners report low knowledge and confidence surrounding naloxone. Therefore, it becomes critical that medical education programs incorporate didactic and experiential sessions improving knowledge, skills and attitudes regarding harm reduction through naloxone. OBJECTIVES: 1. Describe the components and evaluation of a replicable and adaptable naloxone didactic and skills session model for medical providers; 2. Report the results of the evaluation from a pilot session with family medicine residents and physician assistant students; and 3. Share the session toolkit, including evaluation surveys and list of materials used. METHODS: In July 2017, a literature search was completed for naloxone skill training examining best practices on instruction and evaluation. A training session for family medicine residents and physician assistant learners was designed and led by University of Cincinnati College of Medicine and College of Pharmacy faculty. The same faculty designed a pre and post session evaluation form through internal review on elements targeting naloxone knowledge, attitude, and self-efficacy. RESULTS: The training session included one hour for a didactic and one hour for small group live skills demonstration in four methods of naloxone administration (syringe and ampule, nasal atomizer, branded nasal spray and auto injector). Forty-eight participants showed statistically significant (p<0.05) improvement in knowledge (67.5% to 95.9%), attitudes (71.2% to 91.2%), and self-efficacy (62.1% to 97.8%) from pre to post assessment. Forty-four of 48 participants agreed that the pace of the training was appropriate and that the information will be of use in their respective primary care practices. Supply costs for the session were USD 1,200, with the majority being reusable on subsequent trainings. CONCLUSIONS: Our study of a naloxone didactic and skills session for primary care trainees demonstrated significant improvements in knowledge, self-efficacy, and attitudes. It provides an adaptable and efficient model for delivery of knowledge and skills in naloxone administration training. The pilot data suggest that the training was efficacious.

Evaluation of an interprofessional naloxone didactic and skills session with medical residents and physician assistant learners

Background: The CDC has reported 399,230 opioid-related deaths from 1999-2017. In 2018, the US surgeon general issued a public health advisory, advising all Americans to carry naloxone. Studies show that enhanced naloxone access directly reduces death from opioid overdose. Despite this, health care professional learners report low knowledge and confidence surrounding naloxone. Therefore, it becomes critical that medical education programs incorporate didactic and experiential sessions improving knowledge, skills and attitudes regarding harm reduction through naloxone. Objectives: 1. Describe the components and evaluation of a replicable and adaptable naloxone didactic and skills session model for medical providers; 2. Report the results of the evaluation from a pilot session with family medicine residents and physician assistant students; and 3. Share the session toolkit, including evaluation surveys and list of materials used. Methods: In July 2017, a literature search was completed for naloxone skill training examining best practices on instruction and evaluation. A training session for family medicine residents and physician assistant learners was designed and led by University of Cincinnati College of Medicine and College of Pharmacy faculty. The same faculty designed a pre and post session evaluation form through internal review on elements targeting naloxone knowledge, attitude, and self-efficacy. Results: The training session included one hour for a didactic and one hour for small group live skills demonstration in four methods of naloxone administration (syringe and ampule, nasal atomizer, branded nasal spray and auto injector). Forty-eight participants showed statistically significant (p<0.05) improvement in knowledge (67.5% to 95.9%), attitudes (71.2% to 91.2%), and self-efficacy (62.1% to 97.8%) from pre to post assessment. Forty-four of 48 participants agreed that the pace of the training was appropriate and that the information will be of use in their respective primary care practices. Supply costs for the session were USD 1,200, with the majority being reusable on subsequent trainings. Conclusions: Our study of a naloxone didactic and skills session for primary care trainees demonstrated significant improvements in knowledge, self-efficacy, and attitudes. It provides an adaptable and efficient model for delivery of knowledge and skills in naloxone administration training. The pilot data suggest that the training was efficacious

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Meaningful Partnerships: Stages of Development of a Patient and Family Advisory Council at a Family Medicine Residency Clinic.

BACKGROUND: Partnering with patients and families is a crucial step in optimizing health. A patient and family advisory council (PFAC) is a group of patients and family members working together collaboratively with providers and staff to improve health care. OBJECTIVE: This study aimed to describe the creation of a PFAC within a family medicine residency clinic. To understand the successful development of a PFAC, challenges, potential barriers, and positive outcomes of a meaningful partnership will be reported. METHODS: The stages of PFAC development include leadership team formation and initial training, PFAC member recruitment, and meeting launch. Following a description of each stage, outcomes are outlined and lessons learned are discussed. PFAC members completed an open-ended survey and participated in a focus group interview at the completion of the first year. Interviewees provided feedback regarding (1) favorite aspects or experiences, (2) PFAC impact on a family medicine clinic, and (3) future projects to improve care. Common themes will be presented. RESULTS: The composition of the PFAC consisted of 18 advisors, including 8 patient and family advisors, 4 staff advisors, 4 resident physician advisors, and 2 faculty physician advisors. The average meeting attendance was 12 members over 11 meetings in the span of the first year. A total of 13 out of 13 (100%) surveyed participants were satisfied with their experience serving on the PFAC. CONCLUSIONS: PFACs provide a platform for patient engagement and an opportunity to drive home key concepts around collaboration within a residency training program. A framework for the creation of a PFAC, along with lessons learned, can be utilized to advise other residency programs in developing and evaluating meaningful PFACs.

Keeping older patients healthy and safe as they travel.

For older patients, the trip of a lifetime can be fraught with health hazards. There's much you can do to keep them harm free.

Teaching resident physicians chronic disease management: simulating a 10-year longitudinal clinical experience with a standardized dementia patient and caregiver.

BACKGROUND: Education for all physicians should include specialty-specific geriatrics-related and chronic disease-related topics. OBJECTIVE: We describe the development, implementation, and evaluation of a chronic disease/geriatric medicine curriculum designed to teach Accreditation Council for Graduate Medical Education core competencies and geriatric medicine competencies to residents by using longitudinal encounters with a standardized dementia patient and her caregiver daughter. INTERVENTION: Over 3 half-day sessions, the unfolding standardized patient (SP) case portrays the progressive course of dementia and simulates a 10-year longitudinal clinical experience between residents and a patient with dementia and her daughter. A total of 134 residents participated in the University of Cincinnati-based curriculum during 2007-2010, 72% of whom were from internal medicine (79) or family medicine (17) residency programs. Seventy-five percent of participants (100) said they intended to provide primary care to older adults in future practice, yet 54% (73) had little or no experience providing medical care to older adults with dementia. RESULTS: Significant improvements in resident proficiency were observed for all self-reported skill items. SPs' evaluations revealed that residents' use of patient-centered language and professionalism significantly improved over the 3 weekly visits. Nearly all participants agreed that the experience enhanced clinical competency in the care of older adults and rated the program as "excellent" or "above average" compared to other learning activities. CONCLUSIONS: Residents found this SP-based curriculum using a longitudinal dementia case realistic and valuable. Residents improved in both self-perceived knowledge of dementia and the use of patient-centered language and professionalism.

A stroke -- or something else?

The patient -- who'd had a CVA the year before -- was experiencing numbness and weakness in her right leg and foot, and had an increasingly unsteady gait. Initial lab work provided no clues.

Subacute management of ischemic stroke.

Ischemic stroke is the third leading cause of death in the United States and a common reason for hospitalization. The subacute period after a stroke refers to the time when the decision to not employ thrombolytics is made up until two weeks after the stroke occurred. Family physicians are often involved in the subacute management of ischemic stroke. All patients with an ischemic stroke should be admitted to the hospital in the subacute period for cardiac and neurologic monitoring. Imaging studies, including magnetic resonance angiography, carotid artery ultrasonography, and/or echocardiography, may be indicated to determine the cause of the stroke. Evaluation for aspiration risk, including a swallowing assessment, should be performed, and nutritional, physical, occupational, and speech therapy should be initiated. Significant causes of morbidity and mortality following ischemic stroke include venous thromboembolism, pressure sores, infection, and delirium, and measures should be taken to prevent these complications. For secondary prevention of future strokes, antiplatelet therapy with aspirin should be initiated within 24 hours of ischemic stroke in all patients without contraindications, and one of several antiplatelet regimens should be continued long-term. Statin therapy should also be given in most situations. Although permissive hypertension is initially warranted, antihypertensive therapy should begin within 24 hours. Diabetes mellitus should be controlled and patients counseled about lifestyle modifications to reduce stroke risk. Rehabilitative therapy following hospitalization improves outcomes and should be considered.

Gadolinium-associated nephrogenic systemic fibrosis.

Nephrogenic systemic fibrosis is a progressive, potentially fatal multiorgan system fibrosing disease related to exposure of patients with renal failure to the gadolinium-based contrast agents used in magnetic resonance imaging. Because of this relationship between nephrogenic systemic fibrosis and gadolinium-based contrast agents, the U.S. Food and Drug Administration currently warns against using gadolinium-based contrast agents in patients with a glomerular filtration rate less than 30 mL per minute per 1.73 m2, or any acute renal insufficiency related to the hepatorenal syndrome or perioperative liver transplantation. There have been reports of nephrogenic systemic fibrosis developing in patients not exposed to gadolinium-based contrast agents, but most patients have the triad of gadolinium exposure through contrast-enhanced magnetic resonance imaging, renal failure, and a proinflammatory state, such as recent surgery, endovascular injury, or sepsis. Development of nephrogenic systemic fibrosis among patients with severe renal insufficiency following exposure to gadolinium-based contrast agents is approximately 4 percent, and mortality can approach 31 percent. The mechanism for nephrogenic systemic fibrosis is unclear, and current treatments are disappointing. Prevention with hemodialysis immediately following gadolinium-based contrast agents has been recommended, but no studies have shown this to be effective. Because of the large number of patients with clinically silent renal impairment and the serious consequences of nephrogenic systemic fibrosis related to gadolinium exposure, physicians should use alternative imaging modalities for patients who are at risk.

Managing CAP: an evidence-based algorithm.

The 2007 guidelines from the Infectious Diseases Society of America/American Thoracic Society are a blend of level-of-evidence strength and consensus opinion--a unified, evidence-based document. These new recommendations address prior discrepancies between the 2 specialties. We developed a CAP treatment algorithm based on the new advisory.