Sylvia Shellenberger

Applying Team-Based Learning in Primary Care Residency Programs to Increase Patient Alcohol Screenings and Brief Interventions

Purpose Educational research demonstrates little evidence of long-term retention from traditional lectures in residency programs. Team-based learning (TBL), an alternative, active learning technique, incites competition and generates discussion. This report presents data evaluating the ability of TBL to reinforce and enhance concepts taught during initial training in a National Institutes of Health–funded alcohol screening and brief intervention (SBI) program conducted in eight residency programs from 2005 to 2007 under the auspices of Mercer University School of Medicine. Method After initial training of three hours, the authors conducted three TBL booster sessions of one and a quarter hours, spaced four months apart at each site. They assessed feasibility through the amount of preparation time for faculty and staff, residents’ evaluations of their training, self-reported use of SBI, residents’ performance on individual quizzes compared with group quizzes, booster session evaluations, and levels of confidence in conducting SBI. Results After initial training and three TBL reinforcement sessions, 42 residents (63%) reported that they performed SBI and that their levels of confidence in performing interventions in their current and future practices was moderately high. Participants preferred TBL formats over lectures. Group performance was superior to individual performance on initial assessments. When invited to select a model for conducting SBI in current and future practices, all residents opted for procedures that included clinician involvement. Faculty found TBL to be efficient but labor-intensive for training large groups. Conclusions TBL was well received by residents and helped maintain a newly learned clinical skill. Future research should compare TBL to other learning methods.

Developing a Church-Based Diabetes Prevention Program With African Americans Focus Group Findings

Purpose The purpose of this study was to use a community-based participatory research (CBPR) approach to identify resources and barriers to implementing a church-based diabetes prevention program (DPP) in a rural African American church community in Georgia. Methods In collaboration with community leaders, researchers conducted 4 focus groups with 22 key informants to discuss their understanding of diabetes and identify key resources and barriers to implementing a DPP in the church. Three researchers analyzed and coded transcripts following a content-driven immersion-crystallization approach. Results The participants’ comments on diabetes and prevention covered 5 research domains: illness perceptions, illness concerns, illness prevention, religion and coping, and program recommendations. Program success was deemed contingent on cultural sensitivities, a focus on high-risk persons, use of church resources, and addressing barriers. Barriers identified included individuals’lack of knowledge of risk and prevention programs, lack of interest, and attendance concerns. Solutions and resources for overcoming barriers were testimonials from persons with illness, using local media to advertise the program, involving the food committee of the church, ministering to the healthy and at risk, and acquiring a support buddy. Conclusions A CBPR approach engaged church members as partners in developing a church-based DPP. Focus groups generated enthusiasm among church members and provided valuable insights regarding barriers and resources for program implementation. This methodology may prove useful in other church-based chronic disease prevention efforts with at-risk populations.

Skills-Based Residency Training in Alcohol Screening and Brief Intervention: Results from the Georgia-Texas "Improving Brief Intervention" Project.

ABSTRACT Alcohol screening and brief intervention (SBI) is recommended for all primary care patients but is underutilized. This project trained 111 residents and faculty in 8 family medicine residencies to conduct SBI and implement SBI protocols in residency clinics, then assessed changes in self-reported importance and confidence in performing SBI and brief intervention (BI) rates. Clinicians reported significant increases in role security, confidence, and ability to help drinkers reduce drinking and decreased importance of factors that might dissuade them from performing SBI. Stage of change measures indicated 37% of clinicians progressed toward action or maintenance in performing SBI; however, numbers of reported BIs did not increase. At all time points, 33% to 36% of clinicians reported BIs with ≥10% of the last 50 patients. Future studies should focus on increasing intervention rates using more patient-centered BI approaches, quality improvement approaches, and systems changes that could increase opportunities for performing BIs.

Reinventing the Reel: An Innovative Approach to Resident Skill-Building in Motivational Interviewing for Brief Intervention

ABSTRACT To enhance the skills of primary care residents in addressing substance misuse, residency screening, brief intervention, and referral to treatment (SBIRT) programs increasingly offer motivational interviewing (MI) training, but seldom include feedback and coaching. This innovative 2-round “Virginia Reel” approach, supplementing 3 hours of basic MI instruction, was designed to teach and coach residents to use MI while providing ongoing medical care. SBIRT/MI-competent facilitators served as both trainers and actors at 8 carefully sequenced Objective Structured Clinical Examination (OSCE) stations, providing instruction, role-play practice, and feedback on 17 microskills in 2 successive clinical “visits”/rounds addressing alcohol misuse and diabetes management. Evaluation included OSCE checklists, overall competency assessments, and responses to open-ended questions. Three residents showed improvement between rounds. Resident evaluations were strongly positive, identifying practice of MI skills and receipt of coaching and feedback from MI experts as particularly valuable. Further study is needed to confirm effectiveness of the approach and explore the impact of fewer OSCE stations of longer duration.

Cultural genogram: A tool for teaching and practice.

Cultural issues affect patients’, families’, and providers’ perspectives on health, illness, and disease, thus a provider’s sensitivity and awareness to cultural issues can influence the quality and outcome of the patient and family encounter. As the population of the United States becomes more culturally diverse, health care professionals render care to patients whose cultural beliefs, values, attitudes, and health practices differ from their own. The cultural genogram is used as an educational tool to teach health care professionals a structured way to address patients’ and families’ cultural beliefs and practices. This article describes instructional activities for undergraduates, graduates, and faculty; presents a case example and personal reflections of a resident in family medicine; describes practical issues for the clinician; and proposes implications for evaluation and research.

A Multisite Initiative to Increase the Use of Alcohol Screening and Brief Intervention Through Resident Training and Clinic Systems Changes

Purpose Screening and brief intervention (SBI) is a seldom-used evidence-based practice for reducing unhealthy alcohol use among primary care patients. This project assessed the effectiveness of a regional consortium’s training efforts in increasing alcohol SBI. Method Investigators combined alcohol SBI residency training efforts with clinic SBI implementation processes and used chart reviews to assess impact on SBI rates in four residency clinics. Data were derived from a random sample of patient charts collected before (2010; n = 662) and after (2011; n = 656) resident training/clinic implementation. Patient charts were examined for evidence that patients were asked about alcohol use by a validated screening instrument, the screening result (positive or negative), evidence that patients received a brief intervention, prescriptions for medications to assist abstinence, and referrals to alcohol treatment. Chi-square analyses identified differences in pre- and posttraining implementation of SBI practices. Results Following program implementation, screening with validated instruments increased from 151/662 (22.8%) at baseline to 543/656 (82.8%, P < .01), and identification of unhealthy alcohol use increased from 12/662 (1.8%) to 41/656 (6.3%, P < .01). Performance of brief interventions more than doubled (10/662 [1.5%] versus 24/656 [3.7%], P < .01). There were no increases in the use of medications or referrals to treatment. Conclusions Resident training combined with clinic implementation efforts can increase the delivery of evidence-based practices such as alcohol SBI in residency clinics.

Impact of motivational interviewing-based training in screening, brief intervention, and referral to treatment on residents’ self-reported attitudes and behaviors

Many medical residents now receive training in screening, brief intervention, and referral to treatment (SBIRT) for alcohol and drugs. Clinician attitudes have been shown to impact SBIRT-related behaviors. Little research has explored the impact of SBIRT training on clinicians’ attitudes.

Characteristics of Problem Drinking in an Urban South American Indigenous Population

This 2002 Medcen Foundation-funded study explored characteristics of problem drinking among 211 urban Venezuelan Native Americans of Arawak origin. Prevalence of problem drinking using Alcohol Use Disorders Identification Tests was 88.5% among men and 17.3% among women. Periodic binge drinking was marked by loss of control, failure to meet obligations, and alcohol-related trauma. Focus group participants noted that previous occasional binge drinking by men has been replaced by frequent male and female heavy weekend drinking, violence, and death. Limitations and implications are discussed. Awareness of high levels of problem drinking and desire for assistance present compelling mandates for community intervention efforts.

Treatment and Outcomes in Occupational Low Back Pain

ABSTRACT Low back pain (LBP) is the sin gle larg est musculoskeletal injury inthe working pop u la tion, and the sec ond most com mon reason for vis its to pri mary care physicians. D e spite its frequency, thepathologic diagnosis is un certain in 85% of cases. Out comes, particularly in work related LBP vary widely as does treat ment. Numerous guidelines have been re cently promulgated to speed treatment, improve out comes and minimize cost. This study follows 709 workers with low back pain. Methods: Seven hun dred and nine se rial low back pain pa tients werefol lowed through two years. Their charts were au dited for diag nos tics, ther a peutics, refer rals and out comes. The dif fer ingfacets of clinical treatment paradigms are compared with out comes. Results: Out of five cat e go ries, al most half of back in juries re sulted from heavy lift ing alone. Out of 709 pa tients, 1.4% eventu ally re quired sur gery. Only 10 pa tients were clin i cally dis abled at the end of the study pe riod al though a total of 30 did not re turnto work for a va ri ety of reasons. Al most 39% of pa tients re ceived back X-rays, and 10% re ceived MRIs of the lower back. Ninety-three per cent re ceived NSAIDs as part of their treat ment, and 34% nar cot ics. Nei ther NSAIDs nor mus cle re lax-ants cor re lated with prob a bil ity of re turnto work. The me diantreat ment inter val wasseven days, with the ma jor ity of pa tients (551/709) re turned to reg u lar work withintwo weeks of thefirst of ficevisit. Pro longed duration of treat ment and sur gery cor re lated with lit i ga tion. Con clu sions: De spite popular clinical mythology, thevast majority of occupationally acquired low back pain pa tients do re turnto work in a timely fash ion.

impact of a medical student alcohol intervention workshop using recovering alcoholics as simulated patients

Background Alcohol screening and brief intervention (SBI) reduces drinking among at-risk drinkers. Lack of training and negative attitudes represents a barrier to SBI performance. This study evaluates the impact of a medical student workshop using recovering alcoholics in simulated patient interviews to teach SBI skills. Methods Third-year students (n=94) were surveyed before and after a 3-hour alcohol SBI workshop regarding their perceived importance and confidence in performing eleven SBI behaviors. Students were also asked to list factors increasing and decreasing motivation to conduct SBI. Students completing off-campus rotations (n=71) served as controls, completing surveys during the same time period but without attending the workshop. Results Analysis of variance found a significant interaction effect between the students participating in the workshop and control students on both importance scores [F(2,174)=3.34] and confidence scores [F(2,174)=9.13], indicating higher scores for the workshop students at the follow-up time periods. Commonly listed motivators for performing SBI included clinical experience with alcohol misuse and the impact of alcohol on health and relationships. High relapse rates and patient reactions to questions about alcohol use decreased the motivation to perform SBI. Conclusion SBI workshops that include recovering alcoholics as simulated patients can produce long-term improvements in students’ perceived importance and confidence in performing SBI.