Teaching residents screening,brief intervention,and referral to treatment (SBIRT) skills for alcohol use: Using chart-stimulated recall to assess curricular impact

ABSTRACT

Background: Screening, brief intervention, and referral to treatment (SBIRT) improves identification and intervention for patients at risk for developing an alcohol use disorder (AUD). Residency curriculum is designed to teach SBIRT skills, but resources are needed to promote skill implementation. The electronic health record (EHR) can facilitate implementation through integration of decision-support tools. The authors developed electronic tools to facilitate documentation of alcohol assessment and brief intervention and to reinforce skills from an SBIRT curriculum. This prospective cohort study assessed primary care internal medicine residents' use of SBIRT skills and EHR tools in practice using chart-stimulated recall (CSR). Methods: Postgraduate year 2 and 3 residents received a 5-hour SBIRT curriculum with skills practice and instruction on SBIRT electronic tools. Participants were then given a list of their patients seen in a 1-year period who were drinking at/above the recommended limit. Trainees selected 3 patients to review with a faculty member in a CSR. Faculty used a 24-item chart checklist to assess application of SBIRT skills and electronic tool use and met with residents to complete a CSR interview. CSR interview notes were analyzed qualitatively to understand application of SBIRT skills and EHR tool use. Results: Eighteen of 20 residents participated in the CSR, and 5 faculty reviewed 46 patient charts. Residents documented alcohol use (84.2% of charts) and assessment of quantity/frequency of use (71.0%) but were less likely to document assessment for an AUD (34%), an appropriate plan (50.0%), or follow-up (55%). Few residents used EHR tools. Residents reported barriers in addressing alcohol use, including lack of knowledge, patient barriers, and time constraints. Conclusions: More intensive training in SBIRT with opportunities for practice and feedback may be necessary for residents to consistently apply SBIRT skills in practice. EHR tools need to be better integrated into the clinic workflow in order to be useful.     

Utilizing Bloom's taxonomy to design a substance use disorders course for health professions students

Background: Substance use disorders (SUDs) are a public health problem affecting millions of Americans. Despite their prevalence, there are few health care resources allocated for SUDs treatment. Relatively few health care professionals are exposed to SUDs education in their respective programs, which may be one reason for this resource insufficiency. In hopes of rectifying this gap, the authors developed a SUDs course for health professions students combining classroom learning with practical application to patient care. Methods: The authors used Bloom's taxonomy of cognitive, affective, and psychomotor learning domains as an educational framework to create numerous opportunities for students to deepen their knowledge, assess their attitudes, and develop their motivational interviewing skills. The primary outcome of the study was a comparison of students' scores on the Substance Abuse Attitude Scale (SAAS) pre- and post-course completion. Secondary outcome was to compare students' self-assessment scores of their patient counseling with residents' assessments of them on the Liverpool Communication Skills Assessment Scale (LCSAS). Results: One hundred twelve students participated in the authors' SUDs course over a 9-month period. Ninety-five students completed both the pre- and post-course SAAS surveys. The total SAAS survey score and individual domain scores for nonmoralizing, treatment optimism, and treatment intervention demonstrated significant improvement post-course. Eighty-nine students completed a motivational interview with a patient. Eighty students had a LCSAS self-assessment paired with a residents' assessment. Mean scores for individual items on the LCSAS for both groups' assessment were approximately 3.5, indicating that students' communication was assessed as “acceptable” to “good.” Conclusions: This study demonstrates that Bloom's taxonomy was a useful educational framework to ensure a systematic development of the authors' SUDs course. Through participation in our course, students touched each of the 3 domains in Bloom's taxonomy. The authors believe their course design may serve as a framework for future SUDs courses.     

“双一流”建设背景下药学硕士专业学位研究生课程改革思考

目的 探讨药学硕士专业学位研究生课程体系的建设和发展。方法 在全国范围内选出20家有代表性的药学硕士专业学位研究生培养单位,以课程体系建设为研究对象开展调查和访谈。结果 从问题分析和解决的视角研究发现,课程设置与培养目标定位需进一步契合,授课方式需进一步多样化,课程内容需进一步加强针对性,课程资源需进一步丰富。结论 建议通过加强顶层设计、优化课程内容、开展课程共建等途径完善药学硕士专业学位研究生课程体系建设,提高药学高层次应用型人才培养质量。     

First-year Pharmacy Students' Self-Assessment of Communication Skills and the Impact of Video Review

Objectives

To determine the ability of first-year students to self-assess communication skills and measure the impact of video review on students'' self-assessment.

Design

Students participated in a digital video-recorded, counseling-simulation exercise and completed self-assessment before and after viewing their video. A faculty member evaluated the students using the same counseling assessment tool.

Assessment

Correlation between the students'' self-assessment scores and the faculty member''s scores were poor (pre-video: r = 0.38, post-video: r = 0.46). The largest portion of the students overestimated their skills in comparison to the faculty member''s evaluations (47.1% pre-video and 67.9% post-video). Those in the lowest quartile overestimated their skills, while those in the upper quartile underestimated their skills (pre-video). Video review brought about an increase in the self-assessment scores for nearly two-thirds (62.1%) of the students.

Conclusion

First-year pharmacy students had difficulty self-assessing, and video review increased their perception of skill achievement. A curriculum should include opportunities for students to develop self-assessment skills early in the program, and this should be reinforced throughout the curriculum.     

South Texas Residency Screening,Brief Intervention,and Referral to Treatment (SBIRT) Training: 12-Month Outcomes

Background: Screening, brief intervention, and referral to treatment (SBIRT) is an efficacious and cost-effective skill set when implemented in primary care settings regarding hazardous alcohol use. This study assesses the impact of medical resident SBIRT training across 3 specialties and identifies predictors of change in trainee behavior, attitudes, and knowledge over 12 months. Methods: This program's substance use SBIRT training was developed and tailored to fit diverse curricular objectives and settings across an array of medical residency programs in South Texas. The 329 residents training in pediatrics, family medicine, and internal medicine during 2009–2012 constituted the trainee group reported in this analysis. Surveys assessing SBIRT-related knowledge, current practice, confidence, role responsibility, attitudes, beliefs, and readiness to change were completed by 234 (71%) trainees at 3 time points: pre-training, then 30 days and 12 months post-initial training. Results: SBIRT-related knowledge, confidence, and practice increased from pre-training to 12-month follow-up. Residents who reported the least amount of pre-training clinical and/or prior academic exposure to substance use reported the greatest SBIRT practice increases. When controlling for demographic and prior exposure variables, the largest contributor to variance in SBIRT practice was attributed to residents' confidence in their SBIRT skills. Conclusions: SBIRT training that employs diverse educational methodologies as part of customizing the training to residency specialties can similarly enhance SBIRT-related knowledge, confidence, and practice. Trainee report of limited prior clinical or academic exposure to substance use and/or low confidence regarding SBIRT skills and their professional role responsibilities related to substance use predicted trainee success and sustained SBIRT strategy application. When customizing SBIRT training, curriculum developers should consider leveraging and capacity building related to those factors predicting continued use of SBIRT practices.     

Mentally ill chemical abusers in residential treatment programs: Effects of psychopathology on levels of functioning

Measures of psychopathology among mentally ill chemical abusers (MICAs) were examined as predictors of levels of functioning in two types of community based, residential programs: therapeutic community (TC) and community residence (CR). Non-significant associations were generally observed between scales of psychiatric symptoms (e.g., depression, psychotic ideation, cognitive disorientation, and hostility) and counselors' ratings of the residents' capacity to meet the social and interpersonal expectations of the programs (e.g., personal care, involvement in interpersonal relationships, and development of work skills). The study suggests that individuals with moderately severe psychopathology can be successfully engaged in residential treatment, even in programs with relatively high expectations for interpersonal involvement and functioning, such as the therapeutic community.     

Students' Health-Related Quality of Life Across the Preclinical Pharmacy Curriculum

Objectives

To examine health related quality of life (HRQOL), perceived stress, and coping skills in the 3 preclinical years of a doctor of pharmacy (PharmD) curriculum.

Methods

Health-related quality of life, perceived stress, and coping strategies were measured using the Short Form-36, Perceived Stress Scale, and Brief COPE. Average annual scores were compared across curriculum years.

Results

Two hundred thirteen students enrolled in the study. Entering students had physical and mental HRQOL scores that were similar to age-adjusted US norms. Mental HRQOL scores were significantly lower and stress significantly higher during the second year of the PharmD curriculum compared to the first year (p < 0.05). Lower mental HRQOL scores were associated with increased stress and use of maladaptive coping skills in all years of the curriculum.

Conclusion

Increased stress and reduced mental HRQOL were observed across the first 3 years of a PharmD curriculum. Methods to reduce stress and/or use of maladaptive coping skills are needed to improve students'' HRQOL throughout the pharmacy curriculum.     

Concept mapping to evaluate an undergraduate pharmacy curriculum

Objectives

To explore a pharmacy school curriculum for opportunities for student engagement and to determine how these might shape student identity as pharmacists.

Methods

The learning aims and objectives and methods of assessment from the curriculum of a bachelor of pharmacy (BPharm) program were collected and a concept map was generated. The concept map was interpreted using Barnett and Coates'' curricular domains of knowing, acting and being.

Results

The key concepts within the intended curriculum that were identified from the concept map were drugs, pharmacy, understanding, practice, and skills. Concepts such as patient and consumer, which would indicate a patient-centered approach to the curriculum, were limited. The main form of assessment used in the curriculum was multiple-choice and short-answer examinations.

Conclusion

There was an emphasis in the curriculum on student acquisition of knowledge and this was reinforced by the use of theoretical examinations. The content of the curriculum was drug-centered rather than patient-centered and the emergence of students'' identity as pharmacists may be fragmented as a result.     

An Outcomes-based Approach to Curriculum Development in Pharmacy

Objective

To implement an outcomes-based approach to pharmacy curriculum development.

Design

Desired learning outcomes were identified; course content, learning activities, and assessment instruments were designed; and evaluation was conducted and feedback obtained to refine the curriculum.

Assessment

All professional skills, 4 generic capabilities, and the coherence of the curriculum scales showed significant improvement compared to graduates'' performance under both the old and transitional curriculum.

Conclusion

An outcomes-based approach to pharmacy curriculum development provided convincing evidence of enhancement to the curriculum. Such an approach should be considered when implementing or revising pharmacy curriculum.     

Integrating substance abuse treatment for the seriously mentally ill into inpatient psychiatric treatment

This paper offers guidelines for the assessment and treatment of substance abuse problems in seriously mentally ill persons who are admitted into inpatient psychiatric treatment. This approach has been used successfully by the authors and may be most useful in settings where a specialized dual-diagnosis treatment program is not feasible. The first step consists of identifying potential substance abusers using several sources of information including the patient's record, a brief patient interview, and an interview with the patient's family and caseworker. Patients who have a confirmed or suspected substance abuse problem undergo a substance abuse assessment designed to evaluate consumption patterns, the negative consequences of substance use, and high-risk situations for alcohol and drug use. Patients are then presented with individualized feedback in a non-coercive manner, which is intended to increase their motivation to change their substance-use behavior. Treatment consists of a structured coping skills group which covers nine specific topics. The topics covered in the group treatment include both general social skills and specific drug and alcohol coping skills intended to assist individuals in coping effectively with high-risk situations. The content of each group session is described along with guidelines for conducting coping skills group treatment with the seriously mentally ill.     

A Pharmacotherapy Capstone Course to Advance Pharmacy Students�� Clinical Documentation Skills

Objective. To implement and assess the effectiveness of a capstone pharmacotherapy course designed to integrate in-class curriculum using patient cases and drug-information questions. The course was intended to improve third-year doctor of pharmacy (PharmD) students'' clinical documentation skills in preparation for beginning advanced pharmacy practice experiences (APPEs). Design. This 2-credit, semester-long course consisted of 6 patient cases and 12 drug-information questions posted electronically on an Internet-based medical chart, a public health presentation, a knowledge examination, and an objective standardized performance assessment. In class, students engaged in active-learning exercises and clinical problem-solving. Students worked outside of class in small groups to retrieve and discuss assigned articles and review medication information in preparation for in-class discussions.Assessment. A rubric was used to assess the patient cases and questions that students completed and submitted individually. Data for 4 consecutive course offerings (n=622) were then analyzed. A significant improvement was found in the “misplaced” but not the “missing” documentation ratings for both assessment and plan notes in the final assessment compared with baseline. In course evaluations, the majority of students agreed that the course integrated material across the curriculum (97%) and improved their clinical writing skills (80.5%).Conclusion. A capstone pharmacy course was successful in integrating and reviewing much of the material covered across the PharmD curriculum and in improving students’ clinical documentation skills.     

Supplementary pharmacist prescribers' views about communication skills teaching and learning,and applying these new skills in practice

Objective To explore supplementary pharmacist prescribers' (SPPs') views of communication skills teaching and learning, and its impact on their practice. Method Semi‐structured in‐depth telephone interviews. Key findings A total of 66/143 (46%) pharmacists consented to take part. Of these 66, nine SPPs were purposively selected to represent three different sectors of pharmacy: primary care, hospital and community. Questions for a semi‐structured interview schedule were derived from themes identified from SPP self‐reflective essays submitted earlier in the course. Framework analysis was used to interpret the data. SPPs' views of communication skills teaching and learning were positive. Topics raised as particularly useful were how to structure the consultation, eliciting a patient‐centred history, including the patient's perspective on their situation and/or illness, and working in partnership with the patient. However, interviewees highlighted some practical difficulties with putting these new skills into practice. Conclusions The results indicate that SPPs view communication skills training as changing aspects of their consultation practice. The communication skills identified for further development tended to be those not usually required in traditional pharmacy consultations. The results emphasise the importance of providing communication skills training for extended roles.     

Assessment of pharmacy students' communication competence using the Roter Interaction Analysis System during objective structured clinical examinations

Objective

To determine the value of using the Roter Interaction Analysis System during objective structured clinical examinations (OSCEs) to assess pharmacy students'' communication competence.

Methods

As pharmacy students completed a clinical OSCE involving an interview with a simulated patient, 3 experts used a global rating scale to assess students'' overall performance in the interview, and both the student''s and patient''s languages were coded using the Roter Interaction Analysis System (RIAS). The coders recorded the number of utterances (ie, units of spoken language) in each RIAS category. Correlations between the raters'' scores and the number and types of utterances were examined.

Results

There was a significant correlation between students'' global rating scores on the OSCE and the number of utterances in the RIAS socio-emotional category but not the RIAS business category.

Conclusions

The RIAS proved to be a useful tool for assessing the socio-emotional aspect of students'' interview skills.     

家庭医生签约服务模式在居民健康综合护理中的应用研究

目的 研究家庭医生签约模式在社区居民健康综合护理中的成效.方法 选择广州市荔湾区金花街社区186户共620人为研究对象,随机分为两组,观察组采用家庭医生签约服务的方式进行健康综合护理,对照组仅提供常规社区卫生健康服务;进行1年后,对两种模式下的服务效果进行比较,对比两组居民的健康档案建立情况、随访情况、健康知识问卷得分、满意度和疾病痊愈率.结果 观察组的健康档案建立率达到97.1％、随访覆盖率为41.3％、参加健康讲座≥3次率为56.4％,对照组分别为39.7％、16.5％和17.8％,观察组均显著高于对照组(均P＜0.05);随访对象观察组随访频率＜0.5个月比例为11.1％,随访频率0.5～1个月比例为32.5％,对照组分别为1.9％、9.6％,观察组显著高于对照组(P＜0.05);观察组健康知识问卷正确率各项均显著高于对照组(P＜0.05);观察组非常满意比例(85.3％)和总满意比例(98.7％)显著高于对照组(分别为48.9％和90.5％),均P＜0.05;观察组的一般疾病痊愈率(96.2％)显著高于对照组(88.2％)(P＜0.05).结论 在居民健康综合护理中采用家庭医生签约方式能够更有效地掌握住户人群健康状况,更好地普及健康教育,提高居民的满意度和疾病痊愈率,效果更好,值得推广.     

Impact of an Introductory Pharmacy Practice Experience on Students' Performance in an Advanced Practice Experience

Objective

To determine the impact of an introductory pharmacy practice experience (IPPE) on students'' clinical skills during their initial advanced pharmacy practice experience (APPE).

Design

A 4-week First Steps course that focused on students developing pharmacy practice skills, clinical communications skills, and effective use of reference materials was introduced in 2006 at the end of the third-year curriculum, prior to students beginning their APPEs.

Assessment

During the third week of the first APPE, faculty members rated students'' demonstration of 9 clinical skills on a 5-point Likert scale (1 being always and 5 being never). The evaluation was performed in 2005 prior to implementation of the course (control group) and again in 2006 after implementation of the course. Students who completed the First Steps course scored better on all 9 skills and had a better average clinical skills value (2.3) compared to the control group (2.6, p < 0.01).

Conclusion

Completion of an IPPE course that focused on critical pharmacy practice aspects, clinical communication skills, and use of reference materials resulted in increased frequency of desired clinical behaviors on a subsequent APPE.     

Best Practices Assessment to Guide Curricular Change in a Bachelor of Pharmacy Program

Objectives

To identify best practices in global pharmacy education and curriculum design as the basis for decisions about major curriculum change in an existing 4-year bachelor of pharmacy curriculum.

Design

We investigated international best-practice standards, conducted semi-structured interviews with faculty members, and used standardized instruments to investigate student perceptions of the existing curriculum and how they approached their learning.

Assessment

Faculty recommendations included horizontal and vertical integration of curriculum content to replace the previous discipline-based approach; and a theme-based structure underpinned by a detailed statement of learning outcomes that describe the knowledge, skills, and attitudinal milestones to be achieved each year and by the time of graduation. The triangulation of student survey data highlighted issues that needed to be addressed at the individual course unit level, with a particular focus on feedback, assessment, and workload.

Conclusions

The results of the curriculum review provided clear guidance for decisions relating to major curriculum change. An ongoing program of staff development will address the wide range of learning and teaching issues identified by both staff members and students. The results of our investigation of students'' approaches to learning will also be used to guide staff development workshops, focusing on strategies to promote “meaningful learning.”     

A Pharmacy Course on Leadership and Leading Change

Objective

To develop and implement a course that develops pharmacy students'' leadership skills and encourages them to become leaders within the profession.

Design

A leadership course series was offered to pharmacy students on 2 campuses. The series incorporated didactic, experiential, and self-directed learning activities, and focused on developing core leadership skills, self-awareness, and awareness of the process for leading change.

Assessment

Students reported increased knowledge and confidence in their ability to initiate and lead efforts for change. The learning activities students'' valued most were the StrengthsFinder assessment (67% of students rated “very useful”) and a Leadership Networking Partners (LNP) program (83% of students rated “very useful”).

Conclusion

Teaching leadership skills poses a significant challenge in curriculum development and requires multifaceted course design elements that resonate with students and engage the practice community. Addressing these requirements results in a high level of student engagement and a desire to continue the development of leadership skills.