RESUMO
OBJECTIVE: Use an established quality improvement method, Lean A3, to improve the process of opioid prescribing in an academic rheumatology ambulatory clinic. METHODS: This retrospective pre-postintervention analysis of rheumatology records included patients prescribed opioids at least once during the study period. Lean A3 was used to develop a Controlled Substance Visit Protocol to standardize eight recommended elements of the opioid prescribing workflow. Analyses included changes in the recommended workflow elements and changes in opioid prescribing volume. RESULTS: Improvements were observed in seven of the eight recommended elements. Patient education, including treatment agreements and consent forms (39% completion for both preimplementation) increased to 78% and 80%, respectively (P < 0.001 for both). Risk assessment, as measured by the Current Opioid Misuse Measure, increased from 0.5% to 76% (P < 0.001). Best practices in prescribing, including prescribing in multiples of seven to avoid weekend refill requests, increased from 1% to 79% (P < 0.001). Monitoring parameters, including standardized functional assessment (0% vs. 86%), prescription drug monitoring program queries (49% vs. 84%), and urine testing (1% vs. 32%) all increased (P < 0.001). Visits scheduled at least quarterly for patients on chronic opioids did not change (P = 0.18). Overall, the number of patients prescribed opioids (185 vs. 160; P < 0.001) and annual prescription opioid morphine milligram equivalents (MMEs) (1 933 585 MME vs. 1 386 368 MME; P < 0.001) decreased. CONCLUSION: The Lean A3 method is a successful quality improvement tool for improving and sustaining opioid prescribing within a single academic rheumatology clinic. This method has potential applicability to similar clinics interested in improving opioid prescribing.
RESUMO
OBJECTIVE: To determine the reasons trainees choose rheumatology as a subspecialty and to review the literature on career choices among physicians, particularly regarding the choice of subspecialty. METHODS: A questionnaire was designed to identify and analyze factors that influence rheumatology fellows to join the field of rheumatology. The questionnaire was administered online and answers were collated through the American College of Rheumatology Training and Workforce Committee, Subcommittee on Medical Student and Resident Recruitment. We reviewed the medical literature, using Medline and PubMed to find references to career choice among medical trainees. RESULTS: The majority of rheumatology fellows had their initial exposure to rheumatology as second-year and third-year medical students, and >75% solidified their decision during internship and residency. Clinical rotations in rheumatology and exposure to role models and mentors were the most influential factors. Approximately 40% of rheumatology fellows cite their intellectual interest in the field as the most important contributor to their decision. CONCLUSION: Career decision-making occurs throughout medical training. Exposure to clinical experiences and mentors are particularly influential and may have an impact during medical school, as well as during internal medicine residency training. These findings suggest that there are a variety of opportunities throughout medical training to influence career decision-making and improve recruitment into rheumatology. Additional financial resources that support recruitment efforts may be required, and followup studies assessing the effects of these efforts should be done.
