Picker/Gold Graduate Medical Education Challenge Grant Program Cycle: 2009-2010Communication in Family Meetings: Developing and Assessing a Curriculum for ResidentsPrinciple investigator: Julie T. Irish, Ph.D.Beth Israel Deaconess Medical CenterProject goals are to develop a medical education research agenda to investigate optimal educationalstrategies to enhance physician-family and inter-professional communication behaviors and to correlatethem with outcomes of interest. The more immediate goals of the project are: 1) to develop an innovativecurriculum to enhance residents’ communication skills and interactions during family meetings; and 2) toassess the impact of the curriculum through family members’ satisfaction with family meetings. Thespecific objectives of the project are to: 1) deliver the communication curriculum to second year internalmedicine residents; 2) demonstrate that the residents have acquired proficient communication skills usinga rating instrument based on the Kalmazoo Essentials of Communication; and 3) assess and demonstrateimprovement in family members’ satisfaction with family meetings. Project successes will be shared withother Harvard affiliated teaching hospitals as well as the larger GME community; either through theACGME or other accrediting organizations so that they too will have the tools teach these much neededskills. This curriculum will likely be of interest to other residency programs as it aligns with several ofthe ACGME competencies. Results will be published in peer-reviewed journals.Final Analysis: The grantee was successful in ensuring that the 3-week curriculum was delivered to all(over 40) residents who rotated through the selected ICU. They worked closely with staff in thesimulation center to create two realistic and accurate clinical simulations. The family meetingcommunication pocket card was finalized and distributed to house-staff. This pocket card summarized thekey elements of the FAMCAT and provided useful phrases or scripts that were suggested by the criticalcare faculty core. With the input of the members of the project team, a draft manuscript, that describes thedevelopment and delivery of the curriculum, was developed.Improving Patient Communication Skills Among Surgical ResidentsPrinciple investigator: Rajiv Y Chandawarkar MDUniversity of Connecticut Health CenterThe goal of this project is to teach surgical-residents to incorporate communication skills that focus onpatient-centeredness. Surgical and non-surgical residency programs will benefit by helping residentsincorporate patient needs and opinions into the care team’s decision-making process. Clear and empathiccommunication builds stronger relationships between physicians and patients (3-5). The need forpreparing surgical-residents to communicate effectively is high. Mostly, surgical-residents are notformally taught patient-communication and are expected to acquire these skills ‘on the job. Results fromthis study are important for implementation of the educational tools in surgical and non-surgical residencyprograms. Dissemination will be achieved in two ways: intra-institutional implementation, withinUCONN and Yale; and inter-institutional implementation, via presentation at national meetings andpublication.Final Analysis: Results showed that there is an overall improvement in residents’ communication skillsby using a simple, interactive educational program, easily accomplished within the time allotted to
didactic teaching in the educational curriculum. -Case-specific scores showed a statistically significantimprovement. General communication skills (as measured by MIRS) also improved but this improvementwas not statistically significant. Several factors could explain this discrepancy between measuredimprovement in case-specific communication skills, and measured improvement in generalcommunication skills. The first possibility is that while problem-specific skills can -be taught andreinforced in a single day’s training (e.g., through the use of checklists, as recommended by Gawande11ina different context), this may not suffice to ensure improved performance on all MIRS items. Factors suchas lack of jargon, verbal facilitation skills, and summarizing can be taught. However, factors such asempathy, body language and concern for the patient’s viewpoint may have a much larger innatecomponent, making it harder to dissemble over the course of a sustained series of encounters.Develop Health Care Transitions, a Resident Learning Module on Building BridgesPrinciple investigator: Suzanne McLaughlin, MDAlpert School of Medicine, Brown UniversityRhode Island & Hasbro HospitalsThe goal of this project is to develop a transition curriculum for medical residents that will enhanceresidents’ knowledge base of transition issues, develop clinical skills to assess, plan and support transitionfor adolescent and young adult patients and promote residents’ self-efficacy in the integration of patientsand families in the decision-making process through close mentoring of the transition process by facultyand patients who have experienced challenges and success in transition. Dissemination will include peer-reviewed medical education journals and posting to national residency program curriculum websites. On-going work will include the development of ambulatory residency curriculum modules and presentationof curriculum workshops at national meetings.Final Analysis: Throughout the implementation of this transition curriculum, the grantee has beensuccessful in offering transition services in multiple settings and using the experiences to establish acommitted group with regular interactions and successful collaboration on curriculum as well as engagingadministrators at Rhode Island Hospital and the Rhode Island Department of Health to invest in thisprocess. Overall residents reported high levels of satisfaction with the curriculum and clinicalexperiences; residents demonstrated improved knowledge of transition services. This initiative has beenquite successful and with the help of the Rhode Island Department of Health and the Department ofPediatrics at Hasbro Children’s Hospital this initiative will continue for the upcoming year; includingsupport of the community peer support and the transition coordinator positions.Teaching Family-Centeredness in the PICU: a novel approach using medical simulationsPrincipal investigator: Ira M. Cheifetz, MDDuke Childrens HospitalThe focus of the project is to implement a mock code training program in the PICU to providemultidisciplinary training in crisis resource management. An important component of this program willbe to teach strategies that integrate families into these difficult acute care situations. In regards to thePicker Institute’s principles of patient-centered care, this proposal will primarily address the involvementof family and friends, but will also include the principles of respect for patient’s values, preferences, andexpressed needs and information, communication, and education. While this curriculum will be focusedinitially on the PICU, it will be easily generalized to other clinical care areas. We plan to collaborate with
other programs in our institution to supplement their educational curricula and bolster the teaching offamily-centeredness at Duke. Ultimately, we hope to supplement a number of educational curriculathroughout Duke and create a truly integrated simulation-enhanced curriculum that we will publish andpresent on a national stage as a model for educational innovation in the area of family-centered care.Final Analysis: This mock code educational initiative represents an important element of the overallinitiative, and it is clear from the grantee’s experience with this project that opinions of providers in thePICU environment on the issue of family centeredness in the setting of code situations are diverse, andoften extremely passionate. The baseline data, along with further discussions surrounding our initiative,continue to provide interesting insights into the perspectives that PICU providers have in regard to familycenteredness in the PICU, especially in the setting of acute resuscitations. The grantee has been able topositively impact the multidisciplinary team by transforming misperceptions and hopefully improving thecare provided to critically ill children and their families.Introduce a Family Centered Care Curriculum to a Pediatric Residency Program and Measure its Effectson the Centeredness of Pediatric ResidentsPrincipal investigator: Keith J. Mann, MDChildren’s Mercy HospitalThe goal of this project is to develop a curriculum that teaches pediatric residents the knowledge, skillsand behaviors of PFCC and measures the outcomes of physician ‘centeredness’ and family satisfaction.Evidence regarding effective approaches to physician education on patient and family-centered care(PFCC) and the impact on patients and families is needed. The CMHC Family Advisory Board (FAB),the Pediatric Residents, and Medical Education leadership collaborated to create a PFCC curriculum.Program goals and objectives address 4 core principles of the Picker Institute including: (1) respect forpatients’ values, preferences, and expressed needs, (2) information communication and integration, (3)emotional support, and (4) involvement of family and friends. Other principles will be indirectlyaddressed throughout the curriculum. The curriculum will be repeated for each class of residents, creatinga culture of PFCC within the residency program. The culminating ½ day retreat will be taped and/ortelecast for dissemination. We plan to publish our results and share our curriculum.Final Analysis: The grantee successfully integrated family members into the intern orientation,stimulating important discussions of patient and family centered care at the onset of training; also, acommunication workshop was developed and implemented at the intern retreat. The facilitator at theintern retreat used results of the Myers-Briggs Type Inventory (MBTI) to stimulate discussion aroundcommunication in the health care setting. The facilitator then taught and subsequently had the grouppractice specific active listening skills. Overall, 26/28 residents rated it as excellent or above average, 2 asaverage, and 0 as below average or poor. 13 families we recruited for the family as faculty program,completed a teaching workshop and training session for the families, and paired the residents with thefamilies during a “Match Day Lunch” held on April 27th. The training session and lunch with theresidents was well received by the family members. The first two sets of residents (July and August) haveengaged in the patient home visit experience. After the experience the residents had a reflective sessionwith two of the employed family members. These sessions have been enlightening. A Hematology/Oncology was implemented as a mid-rotation seminar that teaches residents the physician’s role andprovide effective communication skills while helping families deal with tragic medical events. To
support their learning, several standardized patients have been trained on four scenarios that involvedifficult communication and the first set of two residents went to the simulation center during late July fortheir standardized patient experience.Transitioning from Pediatric to Adult .Centered Medical Care (the patients perspective)Principal investigator: Niraj Sharma, MD, MPHBrigham and Womens and Boston Childrens HospitalsHarvard Medical SchoolThe goal of the project is to develop a curriculum for medical residents on the transition of children withchronic illnesses to adult-centered care. This project will utilize videotaped interviews with patients andtheir families so that residents will learn directly from the patient’s point of view. This curriculum willspecifically address several Picker Institute’s principles: the families will be asked to discuss issuesrelated to access to care, coordination and integration of health care, sharing information between familiesand providers, communication and education, involvement of family and friends, and transition andcontinuity. The curriculum will be designed to teach these same components to residents. The initialstudy will be conducted at Brigham and Women’s Hospital and Children’s Hospital Boston. After thefirst session is completed, results will be presented as a workshop at a national program directorsassociation meeting (e.g. Association of Program Directors in Internal Medicine) to show itseffectiveness. The long-term goal is to develop the curriculum both on DVD and online so it can beeasily accessed nationally by medical students and faculty practitioners as well as residents at otherprograms.Current Status: This project has received a no cost extension until June 2012.Screening and Managing Interpersonal Violence During Pregnancy at an Urban Teaching HospitalPrinciple investigator: Suneet Chauhan, MDAurora Health Care, Inc.Through this project, residents will be trained to consistently screen pregnant patients for IPV (intimatepartner violence) and, if it is present, refer them to violence intervention centers and other supportnetworks. Since the majority of patients are not victims of verbal or physicalabuse, the challenge is tosensitively and effectively identify those who are. IPV screening takes skill and persistence on the part ofthe healthcare provider, as it may take as many as six interactions with a healthcare provider for anabused woman to disclose the violence. This project will help residents improve their skills and tune in totheir patients. At the completion of the study, results will be shared with the house staff, labor anddelivery nurses, midwives, and faculty at the teaching hospital. Results will also be shared with the nineother hospitals within Aurora Health Care providing obstetrical services. Findings will be presented at thenext year’s American College of Obstetricians and Gynecologists (ACOG), May, 15 – 19, 2010 in SanFrancisco, CA, to enable other OBGYN residency program directors to implement similar curricula.Lastly, the results of the study will be published in a peer-reviewed journal such as the American Journalof Perinatology.Final Analysis: The grantee developed of a team approach to treating women experiencing IPV as theattending staff, midwives, and labor and delivery nurses learned how to work with women experiencingIPV to help them connect with patient-determined resources including legal advocacy, shelter, clothing,
and food, ancillary medical needs, and social services and counseling. The project team has completedthe data analysis and the manuscript to share with other resident programs. This project will ultimatelyculminate with the presentation of the research at the ACOG 2011 National Convention and publicationin a peer reviewed journal. Data analysis reveals a total of 100 patients were screened with three patientswith positive screen results and subsequent follow-up with the Safe Mom Safe Baby Program. Sixty-seven percent of the patients were African American, twenty percent Latino and ten percent Caucasian.The average gestational age was thirty-nine weeks. The average birth weight was 3019 grams.Create a patient-centered care plan (PCCP) within an electronic medical record; and evaluate the impactof PCCP use on patients and health-care team membersPrincipal Investigators: Judith Pauwels, MD (Program Director), Larry Mauksch, M.EdUniv. of WA Family Medicine ResidencyThe project will focus on the following Picker Institute principles of patient-centered care: respect forpatients’ values, preferences, and expressed needs; coordination and integration of care; information,communication, and education. These principles will be addressed through the formation of a new EHRsection called the Patient-Centered Care Plan (PCCP). This project’s goal is to use the PCCP torestructure our current model of care to foster patient-centered care. This work will be distributedthrough local, regional, and national presentations and through submission to academic and primary carejournals. This work will be distributed through local, regional, and national presentations and throughsubmission to academic and primary care journals.Final Analysis: An equal distribution of faculty, and residents (equal distribution across three years) wererecruited for the experimental (8) and control groups (7). The grantee also recruited and trained themedical assistant for the experimental group but no medical assistants were involved it the control group.Patients with one or more chronic illnesses and a prior visit with the physician designated at their PrimaryCare Physician were approached to participate. The grantee did not gather information about patientswho refused. Experimental group patients were younger and a higher percentage were female. Althoughthey had the same number of chronic conditions, they had twice as many reasons for the visit recordedcompared to control patients. This is probably the result of PCCP training for the medical assistant thatincluded upfront agenda setting. We recruited 28 experimental group patients across 8 providers and 30control patients across 7 providers. The experimental group charts had significantly (p<.0001) moredocumentation of all 8 goal setting criteria compared to control charts. The Experimental group patientsshowed a trend on surveys to indicate higher levels of activation. The Experimental group providers, theirpatients, and the medical assistant believe our training was effective and that the model was useful inpromoting teamwork, patient engagement, patient self-management, provider skill development andcontinuity. A future improvement in the design and implementation of the PCCP needs to include newEHR design, more time for medical assistants, training in patient selection and engagement. The projectwas presented at the annual meeting of the Society of Teachers of Family Medicine. The grantee hassubmitted a proposal to summarize the research findings at the 2011 Society of Teachers of FamilyMedicine annual meeting. Further dissemination will occur through the Washington State Department ofHealth and through publication in peer-reviewed journals.