Practice Management

President-elect Joe Biden has nominated California Attorney General Xavier Becerra to run the US Department of Health & Human Services (HHS) under his new administration, according to a statement from the Biden-Harris transition team.

Rich Pedroncelli/AP

If confirmed by the US Senate, Becerra will face the challenge of overseeing the federal agency charged with protecting the health of all Americans in the midst of the COVID-19 pandemic. At the time of the announcement, nearly 15 million Americans had tested positive for COVID-19 and more than 280,000 had died.

Becerra served 12 terms in Congress, representing the Los Angeles area. Although his public health experience is limited, he served on the Congressional Ways and Means Committee overseeing health-related issues. Becerra is known as an advocate for the health and well-being of women in particular.

The American College of Physicians, American Academy of Pediatrics, American College of Obstetricians & Gynecologists, American Academy of Family Physicians, and the American Psychiatric Association wrote a letter to Biden on December 3 urging him to select leaders with medical and healthcare expertise, in particular physicians.

“We believe that your administration and the country would be well-served by the appointment of qualified physicians to serve in key positions critical to advancing the health of our nation,” they wrote. “Therefore, our organizations, which represent more than 400,000 front-line physicians practicing in the United States, write to request that you identify and appoint physicians to healthcare leadership positions within your administration.”
 

Recent advocacy

Becerra has worked with Republican attorneys general to lobby HHS to increase access to remdesivir to treat people with COVID-19.

As attorney general, Becerra filed more than 100 lawsuits against the Trump administration. In November, he also represented more than 20 states in arguments supporting the Affordable Care Act before the Supreme Court.

On December 4, Becerra joined with attorneys general from 23 states and the District of Columbia opposing a proposed rule from the outgoing Trump administration. The rule would deregulate HHS and “sunset”many agency provisions before Trump leaves office next month.

Becerra will be the first Latino appointed as HHS secretary, which furthers Biden’s goal to create a diverse cabinet. Becerra has been attorney general of California since 2017, replacing Vice President-elect Kamala Harris when she became senator.

Biden’s choice of Becerra was unexpected, according to The New York Times, and he was not the only candidate. Speculation was that Biden initially considered Vivek Murthy, MD, later chosen as the next US surgeon general, as well New Mexico Gov. Michelle Lujan Grisham and Rhode Island Gov. Gina Raimondo.
 

A huge undertaking

As HHS secretary, Becerra would oversee a wide range of federal agencies, including the US Food and Drug Administration, the Centers for Disease Control and Prevention, the National Institutes of Health, and the Centers for Medicare & Medicaid Services.

The fiscal year 2021 budget proposed for HHS includes $94.5 billion in discretionary budget authority and $1.3 trillion in mandatory funding. Overall, HHS controls nearly one quarter of all federal expenditures and provides more grant money than all other federal agencies combined.

Becerra, 62, grew up in Sacramento, California. He was the first in his family to graduate from college. He received his undergraduate and law degrees from Stanford University.

This article first appeared on Medscape.com.

President-elect Joe Biden has nominated California Attorney General Xavier Becerra to run the US Department of Health & Human Services (HHS) under his new administration, according to a statement from the Biden-Harris transition team.

Rich Pedroncelli/AP

If confirmed by the US Senate, Becerra will face the challenge of overseeing the federal agency charged with protecting the health of all Americans in the midst of the COVID-19 pandemic. At the time of the announcement, nearly 15 million Americans had tested positive for COVID-19 and more than 280,000 had died.

Becerra served 12 terms in Congress, representing the Los Angeles area. Although his public health experience is limited, he served on the Congressional Ways and Means Committee overseeing health-related issues. Becerra is known as an advocate for the health and well-being of women in particular.

The American College of Physicians, American Academy of Pediatrics, American College of Obstetricians & Gynecologists, American Academy of Family Physicians, and the American Psychiatric Association wrote a letter to Biden on December 3 urging him to select leaders with medical and healthcare expertise, in particular physicians.

“We believe that your administration and the country would be well-served by the appointment of qualified physicians to serve in key positions critical to advancing the health of our nation,” they wrote. “Therefore, our organizations, which represent more than 400,000 front-line physicians practicing in the United States, write to request that you identify and appoint physicians to healthcare leadership positions within your administration.”
 

Recent advocacy

Becerra has worked with Republican attorneys general to lobby HHS to increase access to remdesivir to treat people with COVID-19.

As attorney general, Becerra filed more than 100 lawsuits against the Trump administration. In November, he also represented more than 20 states in arguments supporting the Affordable Care Act before the Supreme Court.

On December 4, Becerra joined with attorneys general from 23 states and the District of Columbia opposing a proposed rule from the outgoing Trump administration. The rule would deregulate HHS and “sunset”many agency provisions before Trump leaves office next month.

Becerra will be the first Latino appointed as HHS secretary, which furthers Biden’s goal to create a diverse cabinet. Becerra has been attorney general of California since 2017, replacing Vice President-elect Kamala Harris when she became senator.

Biden’s choice of Becerra was unexpected, according to The New York Times, and he was not the only candidate. Speculation was that Biden initially considered Vivek Murthy, MD, later chosen as the next US surgeon general, as well New Mexico Gov. Michelle Lujan Grisham and Rhode Island Gov. Gina Raimondo.
 

A huge undertaking

As HHS secretary, Becerra would oversee a wide range of federal agencies, including the US Food and Drug Administration, the Centers for Disease Control and Prevention, the National Institutes of Health, and the Centers for Medicare & Medicaid Services.

The fiscal year 2021 budget proposed for HHS includes $94.5 billion in discretionary budget authority and $1.3 trillion in mandatory funding. Overall, HHS controls nearly one quarter of all federal expenditures and provides more grant money than all other federal agencies combined.

Becerra, 62, grew up in Sacramento, California. He was the first in his family to graduate from college. He received his undergraduate and law degrees from Stanford University.

This article first appeared on Medscape.com.

President-elect Joe Biden has nominated California Attorney General Xavier Becerra to run the US Department of Health & Human Services (HHS) under his new administration, according to a statement from the Biden-Harris transition team.

Rich Pedroncelli/AP

If confirmed by the US Senate, Becerra will face the challenge of overseeing the federal agency charged with protecting the health of all Americans in the midst of the COVID-19 pandemic. At the time of the announcement, nearly 15 million Americans had tested positive for COVID-19 and more than 280,000 had died.

Becerra served 12 terms in Congress, representing the Los Angeles area. Although his public health experience is limited, he served on the Congressional Ways and Means Committee overseeing health-related issues. Becerra is known as an advocate for the health and well-being of women in particular.

The American College of Physicians, American Academy of Pediatrics, American College of Obstetricians & Gynecologists, American Academy of Family Physicians, and the American Psychiatric Association wrote a letter to Biden on December 3 urging him to select leaders with medical and healthcare expertise, in particular physicians.

“We believe that your administration and the country would be well-served by the appointment of qualified physicians to serve in key positions critical to advancing the health of our nation,” they wrote. “Therefore, our organizations, which represent more than 400,000 front-line physicians practicing in the United States, write to request that you identify and appoint physicians to healthcare leadership positions within your administration.”
 

Recent advocacy

Becerra has worked with Republican attorneys general to lobby HHS to increase access to remdesivir to treat people with COVID-19.

As attorney general, Becerra filed more than 100 lawsuits against the Trump administration. In November, he also represented more than 20 states in arguments supporting the Affordable Care Act before the Supreme Court.

On December 4, Becerra joined with attorneys general from 23 states and the District of Columbia opposing a proposed rule from the outgoing Trump administration. The rule would deregulate HHS and “sunset”many agency provisions before Trump leaves office next month.

Becerra will be the first Latino appointed as HHS secretary, which furthers Biden’s goal to create a diverse cabinet. Becerra has been attorney general of California since 2017, replacing Vice President-elect Kamala Harris when she became senator.

Biden’s choice of Becerra was unexpected, according to The New York Times, and he was not the only candidate. Speculation was that Biden initially considered Vivek Murthy, MD, later chosen as the next US surgeon general, as well New Mexico Gov. Michelle Lujan Grisham and Rhode Island Gov. Gina Raimondo.
 

A huge undertaking

As HHS secretary, Becerra would oversee a wide range of federal agencies, including the US Food and Drug Administration, the Centers for Disease Control and Prevention, the National Institutes of Health, and the Centers for Medicare & Medicaid Services.

The fiscal year 2021 budget proposed for HHS includes $94.5 billion in discretionary budget authority and $1.3 trillion in mandatory funding. Overall, HHS controls nearly one quarter of all federal expenditures and provides more grant money than all other federal agencies combined.

Becerra, 62, grew up in Sacramento, California. He was the first in his family to graduate from college. He received his undergraduate and law degrees from Stanford University.

This article first appeared on Medscape.com.

Vaccines work. They are powerful tools that have saved millions of lives worldwide; however, a robust antivaccine movement has taken hold in the United States and worldwide despite overwhelming data in support of vaccination. In fact, vaccine hesitancy—the reluctance or refusal to vaccinate despite the availability of vaccines—was listed by the World Health Organization as one of the top 10 global health threats in 2019.¹

Several vaccines have a role in dermatology, including the human papillomavirus (HPV) vaccine (Gardasil 9 [Merck Sharp & Dohme Corp]), the herpes zoster vaccines (Zostavax [Merck Sharp & Dohme Corp] and Shingrix [GlaxoSmithKline Biologicals]), and the measles-mumps-rubella vaccine, among others. These vaccinations are necessary for children and many adults alike, and they play a critical role in protecting both healthy and immunosuppressed patients.

Vaccine hesitancy is a growing threat to individual and public health that requires a response from all physicians. In our experience, dermatologists have been somewhat passive in advocating for vaccinations, possibly due to knowledge barriers or time constraints; however, this stance must change. Dermatologists must join the front lines in advocating for vaccinations, which are a proven and effective modality in promoting public health.

Dermatologists can employ the following practical tips to improve vaccination compliance among patients:

• Familiarize yourself with the Centers for Disease Control and Prevention immunization schedules and vaccination information sheets (https://www.cdc.gov/vaccines/hcp/vis/current-vis.html). Printed copies of informational handouts should be readily available to provide to patients in the office. The Centers for Disease Control and Prevention also offers tip sheets to guide conversations with patients (https://www.cdc.gov/vaccines/hcp/conversations/index.html).

• Prior to starting an immunosuppressive medication, confirm the patient’s immunization status. You should know which vaccines are live (containing an attenuated pathogen) and which are inactivated. Live vaccines typically are not administered to immunosuppressed patients.

• Use electronic medical records to help provide reminders to prompt administration of any necessary vaccines.

• Know the facts, especially regarding purported vaccine controversies, and be able to cite data on vaccine safety and efficacy. For example, when having a conversation with a patient you could state that vaccination against HPV, which can cause genital warts and certain cancers, has decreased the number of HPV infections by more than 70% in young women and 80% in teenaged girls.² Cervical precancers were reduced by 40% in women vaccinated against HPV. Twelve years of monitoring data validates the safety and efficacy of the HPV vaccine—it is safe and effective, with benefits that outweigh any potential risks.²

• Tailor counseling based on the patient’s age and focus on benefits that directly impact the patient. For example, consider showing young adults photographs of genital warts while educating them that the HPV vaccine can help prevent this kind of infection in the future.

• Emphasize that vaccines are a routine part of comprehensive patient care and support this point by providing data and specific reasons for recommending vaccines.³ Avoid phrases such as, “Do you want the vaccine?” or “You could consider receiving the vaccine today,” which can imply that the vaccine is not necessary.

• Offer vaccines in your office or provide clear printed informational sheets directing patients to nearby primary care clinics, infectious disease clinics, or pharmacies where vaccinations are offered.

• Consider using social media to promote the benefits of vaccination among patients.

The recent coronavirus disease 2019 pandemic has brought the topic of vaccination into the limelight while highlighting that rampant misinformation can lead to distrust of health care workers. Dermatologists, along with all physicians, should be trusted advisors and advocates for public health. In addition to being knowledgeable, dermatologists must remain open-minded in having conversations with skeptical patients. Physicians must take the time and effort to promote vaccinations—the health of patients and the general public depends on it.

Vaccines work. They are powerful tools that have saved millions of lives worldwide; however, a robust antivaccine movement has taken hold in the United States and worldwide despite overwhelming data in support of vaccination. In fact, vaccine hesitancy—the reluctance or refusal to vaccinate despite the availability of vaccines—was listed by the World Health Organization as one of the top 10 global health threats in 2019.¹

Several vaccines have a role in dermatology, including the human papillomavirus (HPV) vaccine (Gardasil 9 [Merck Sharp & Dohme Corp]), the herpes zoster vaccines (Zostavax [Merck Sharp & Dohme Corp] and Shingrix [GlaxoSmithKline Biologicals]), and the measles-mumps-rubella vaccine, among others. These vaccinations are necessary for children and many adults alike, and they play a critical role in protecting both healthy and immunosuppressed patients.

Vaccine hesitancy is a growing threat to individual and public health that requires a response from all physicians. In our experience, dermatologists have been somewhat passive in advocating for vaccinations, possibly due to knowledge barriers or time constraints; however, this stance must change. Dermatologists must join the front lines in advocating for vaccinations, which are a proven and effective modality in promoting public health.

Dermatologists can employ the following practical tips to improve vaccination compliance among patients:

• Familiarize yourself with the Centers for Disease Control and Prevention immunization schedules and vaccination information sheets (https://www.cdc.gov/vaccines/hcp/vis/current-vis.html). Printed copies of informational handouts should be readily available to provide to patients in the office. The Centers for Disease Control and Prevention also offers tip sheets to guide conversations with patients (https://www.cdc.gov/vaccines/hcp/conversations/index.html).

• Prior to starting an immunosuppressive medication, confirm the patient’s immunization status. You should know which vaccines are live (containing an attenuated pathogen) and which are inactivated. Live vaccines typically are not administered to immunosuppressed patients.

• Use electronic medical records to help provide reminders to prompt administration of any necessary vaccines.

• Know the facts, especially regarding purported vaccine controversies, and be able to cite data on vaccine safety and efficacy. For example, when having a conversation with a patient you could state that vaccination against HPV, which can cause genital warts and certain cancers, has decreased the number of HPV infections by more than 70% in young women and 80% in teenaged girls.² Cervical precancers were reduced by 40% in women vaccinated against HPV. Twelve years of monitoring data validates the safety and efficacy of the HPV vaccine—it is safe and effective, with benefits that outweigh any potential risks.²

• Tailor counseling based on the patient’s age and focus on benefits that directly impact the patient. For example, consider showing young adults photographs of genital warts while educating them that the HPV vaccine can help prevent this kind of infection in the future.

• Emphasize that vaccines are a routine part of comprehensive patient care and support this point by providing data and specific reasons for recommending vaccines.³ Avoid phrases such as, “Do you want the vaccine?” or “You could consider receiving the vaccine today,” which can imply that the vaccine is not necessary.

• Offer vaccines in your office or provide clear printed informational sheets directing patients to nearby primary care clinics, infectious disease clinics, or pharmacies where vaccinations are offered.

• Consider using social media to promote the benefits of vaccination among patients.

The recent coronavirus disease 2019 pandemic has brought the topic of vaccination into the limelight while highlighting that rampant misinformation can lead to distrust of health care workers. Dermatologists, along with all physicians, should be trusted advisors and advocates for public health. In addition to being knowledgeable, dermatologists must remain open-minded in having conversations with skeptical patients. Physicians must take the time and effort to promote vaccinations—the health of patients and the general public depends on it.

Vaccines work. They are powerful tools that have saved millions of lives worldwide; however, a robust antivaccine movement has taken hold in the United States and worldwide despite overwhelming data in support of vaccination. In fact, vaccine hesitancy—the reluctance or refusal to vaccinate despite the availability of vaccines—was listed by the World Health Organization as one of the top 10 global health threats in 2019.¹

Several vaccines have a role in dermatology, including the human papillomavirus (HPV) vaccine (Gardasil 9 [Merck Sharp & Dohme Corp]), the herpes zoster vaccines (Zostavax [Merck Sharp & Dohme Corp] and Shingrix [GlaxoSmithKline Biologicals]), and the measles-mumps-rubella vaccine, among others. These vaccinations are necessary for children and many adults alike, and they play a critical role in protecting both healthy and immunosuppressed patients.

Vaccine hesitancy is a growing threat to individual and public health that requires a response from all physicians. In our experience, dermatologists have been somewhat passive in advocating for vaccinations, possibly due to knowledge barriers or time constraints; however, this stance must change. Dermatologists must join the front lines in advocating for vaccinations, which are a proven and effective modality in promoting public health.

Dermatologists can employ the following practical tips to improve vaccination compliance among patients:

• Familiarize yourself with the Centers for Disease Control and Prevention immunization schedules and vaccination information sheets (https://www.cdc.gov/vaccines/hcp/vis/current-vis.html). Printed copies of informational handouts should be readily available to provide to patients in the office. The Centers for Disease Control and Prevention also offers tip sheets to guide conversations with patients (https://www.cdc.gov/vaccines/hcp/conversations/index.html).

• Prior to starting an immunosuppressive medication, confirm the patient’s immunization status. You should know which vaccines are live (containing an attenuated pathogen) and which are inactivated. Live vaccines typically are not administered to immunosuppressed patients.

• Use electronic medical records to help provide reminders to prompt administration of any necessary vaccines.

• Know the facts, especially regarding purported vaccine controversies, and be able to cite data on vaccine safety and efficacy. For example, when having a conversation with a patient you could state that vaccination against HPV, which can cause genital warts and certain cancers, has decreased the number of HPV infections by more than 70% in young women and 80% in teenaged girls.² Cervical precancers were reduced by 40% in women vaccinated against HPV. Twelve years of monitoring data validates the safety and efficacy of the HPV vaccine—it is safe and effective, with benefits that outweigh any potential risks.²

• Tailor counseling based on the patient’s age and focus on benefits that directly impact the patient. For example, consider showing young adults photographs of genital warts while educating them that the HPV vaccine can help prevent this kind of infection in the future.

• Emphasize that vaccines are a routine part of comprehensive patient care and support this point by providing data and specific reasons for recommending vaccines.³ Avoid phrases such as, “Do you want the vaccine?” or “You could consider receiving the vaccine today,” which can imply that the vaccine is not necessary.

• Offer vaccines in your office or provide clear printed informational sheets directing patients to nearby primary care clinics, infectious disease clinics, or pharmacies where vaccinations are offered.

• Consider using social media to promote the benefits of vaccination among patients.

The recent coronavirus disease 2019 pandemic has brought the topic of vaccination into the limelight while highlighting that rampant misinformation can lead to distrust of health care workers. Dermatologists, along with all physicians, should be trusted advisors and advocates for public health. In addition to being knowledgeable, dermatologists must remain open-minded in having conversations with skeptical patients. Physicians must take the time and effort to promote vaccinations—the health of patients and the general public depends on it.

From the UT Health Long School of Medicine San Antonio, Texas.

Abstract

Objective: To educate pregnant patients with opioid use disorder (OUD) about the effects of opioids in order to improve understanding and help achieve sustained abstinence.

Methods: The Center for Health Care Services and University Hospital System (UHS) in San Antonio, TX, jointly operate a methadone clinic, the Mommies Program, for pregnant women with OUD. As part of this program, medical students discuss methadone use in pregnancy and the health effects of OUD on mother and child and review resources for sustained peripartum abstinence at prenatal visits with pregnant patients with OUD concurrently enrolled in the program. To evaluate the impact of this education intervention, students assessed patients’ knowledge of methadone effects on mother and baby, state laws concerning heroin and methadone use in pregnancy, and motivation to quit using opioids with pre- and post-intervention surveys.

Results: Of 68 women enrolled in the program, 33 completed both the pre-survey and the post-survey (48.5%). Nearly half (48%) were very motivated to quit before pregnancy, but 85% were very motivated to quit once pregnant. All participants said learning more about the effects of opiates would increase motivation for sobriety. Prior to the educational intervention, 39% of participants knew it was safe to breastfeed on methadone, which improved to 97% in the post-survey, and 76% incorrectly thought they would be reported to authorities by their health care providers if they used illegal drugs during pregnancy, while in the post-survey, 100% knew they would not be reported for doing so.

Conclusion: Pregnancy and education about opioids increased patients’ motivation to quit. Patients also advanced their breastfeeding knowledge and learned about patient-provider confidentiality. Our greatest challenge was participant follow-up; however, this improved with the help of a full-time Mommies Program nurse. Our future aim is to increase project awareness and extend the educational research.

Keywords: pregnancy; addiction; opioids; OUD; counseling.

In 2012 more than 259 million prescriptions for opioids were written in the United States, which was a 200% increase since 1998.¹ Since the early 2000s, admissions to opioid substance abuse programs and the death rate from opioids have quadrupled.^2-4 Specifically, the rate of heroin use increased more than 300% from 2010 to 2014.⁵ Opioid use in pregnancy has also escalated in recent years, with a 3- to 4-fold increase from 2000 to 2009 and with 4 in 1000 deliveries being complicated by opioid use disorder (OUD) in 2011.^6-8

Between 2000 and 2014, the maternal mortality rate in the United States increased 24%, making it the only industrialized nation with a maternal mortality rate that is rising rather than falling.⁹ The Texas Maternal Mortality and Morbidity Task Force found that between 2012 and 2015 drug overdose was the leading cause of maternal death in the period from delivery to 365 days postpartum, and it has increased dramatically since 2010.^10,11

In addition, maternal mortality reviews in several states have identified substance use as a major risk factor for pregnancy-associated deaths.^12,13 In Texas between 2012 and 2015, opioids were found in 58% of maternal drug overdoses.¹⁰ In 2007, 22.8% of women who were enrolled in Medicaid programs in 46 states filled an opioid prescription during pregnancy.¹⁴ Additionally, the rising prevalence of opioid use in pregnancy has led to a sharp increase in neonatal abstinence syndrome (NAS), rising from 1.5 cases per 1000 hospital births in 1999 to 6.0 per 1000 hospital births in 2013.¹⁵ Unsurprisingly, states with the highest rates of opioid prescribing also have the highest rates of NAS.¹⁶

Methadone combined with counseling and behavioral therapy has been the standard of care for the treatment of OUD in pregnancy since the 1970s. Methadone treatment prevents opioid withdrawal symptoms and increases adherence to prenatal care.¹⁷ One of the largest methadone treatment clinics in the San Antonio, TX, area is the Center for Health Care Services (CHCS). University Health System in San Antonio (UHS) has established a clinic called The Mommies Program, where mothers addicted to opioids can receive prenatal care by a dedicated physician, registered nurse, and a certified nurse midwife, who work in collaboration with the CHCS methadone clinic. Pregnant patients with OUD in pregnancy are concurrently enrolled in the Mommies Program and receive prenatal care through UHS and methadone treatment and counseling through CHCS. The continuity effort aims to increase prenatal care rates and adherence to methadone treatment.

Once mothers are off illicit opioids and on methadone, it is essential to discuss breastfeeding with them, as many mothers addicted to illicit opioids may have been told that they should not be breastfeeding. However, breastfeeding should be encouraged in women who are stable on methadone if they are not using illicit drugs and do not have other contraindications, regardless of maternal methadone dose, since the transfer of methadone into breast milk is minimal.^18-20 Breastfeeding is beneficial in women taking methadone and has been associated with decreased severity of NAS symptoms, decreased need for pharmacotherapy, and a shorter hospital stay for the baby.²¹ In addition, breastfeeding contributes to the development of an attachment between mother and infant, while also providing the infant with natural immunity. Women should be counseled about the need to stop breastfeeding in the event of a relapse.²²

Finally, the postpartum period represents a time of increased stressors, such as loss of sleep, child protective services involvement, and frustration with constant demands from new baby. For mothers with addiction, this is an especially sensitive time, as the stressors may be exacerbated by their new sobriety and a sudden end to the motivation they experienced from pregnancy.²³ Therefore, early and frequent postpartum care with methadone dose evaluation is essential in order to decrease drug relapse and screen for postpartum depression in detail, since patients with a history of drug use are at increased risk of postpartum depression.

In 2017 medical students at UT Health Long School of Medicine in San Antonio created a project to educate women about OUD in pregnancy and provide motivational incentives for sustained abstinence; this project has continued each year since. Students provide education about methadone treatment and the dangers of using illicit opioids during and after pregnancy. Students especially focus on educating patients on the key problem areas in the literature, such as overdose, NAS, breastfeeding, postpartum substance use, and postpartum depression.

Methods

From October 2018 to February 2020, a total of 15 medical students volunteered between 1 and 20 times at the Mommies Program clinic, which was held once or twice per week from 8 am to 12 pm. Prior to attending clinic, a fourth-year medical student oriented that year’s group of first-, second-, and third-year medical students who volunteered to attend the clinic. The orientation introduced students to the Mommies Program and instructed them on how and why methadone is prescribed and distributed. Students were also taught how to begin and proceed through each patient encounter, and were given a standard handout to review with patients. This handout made it possible for students of every level to attend the Mommies Program and ensured that the education was standardized at every session (Figure 1).

The only inclusion criteria for participating in the educational intervention and survey was participants had to be 18 years of age or older and enrolled in the Mommies Program. Patients who met the inclusion criteria and agreed to participate completed a pre-survey administered by the students during the patient’s initial prenatal visit (Figure 2). This survey collected baseline information about the patient’s history with opioid use and their current knowledge of methadone treatment, NAS, legal aspects of drug use disclosure, and drug testing prior to the education portion of the encounter. After the pre-survey was administered, students spent 30 minutes reviewing the correct answers of the survey with the patients by utilizing the standardized handout to help patients understand details of methadone and opioid use in pregnancy (Figure 1). The post-survey was administered by a student once patients entered the third trimester to assess whether the education session increased patients’ knowledge of these topics.

At the time patients completed the post-survey, they received a Baby Bag as well as education regarding each item in the bag. The aim of distributing Baby Bags was to relieve some possible postnatal stressors and educate the patients about infant care. Items included in the bag were diapers, wipes, bottles, clothes, and swaddles. Prenatal vitamins were added in January 2020, as many patients struggle to afford vitamins if they are not currently covered by Medicaid or have other barriers. The Baby Bag items were purchased through a Community Service Learning grant through UT Health San Antonio.

Results

Of 68 women enrolled in the Mommies Program during the intervention period, 33 completed the pre-survey and the post-survey (48.5%). Even though all patients enrolled in the program met the inclusion criteria, patients were not included in the educational program for multiple reasons, including refusal to participate, poor clinic follow-up, or lack of students to collect surveys. However, all patients who completed the pre-survey did complete the post-survey. In the pre-survey, only 39% of participants knew it was safe to breastfeed while on methadone. In the post-survey, 97% knew it safe to breastfeed. Nearly half (48%) reported being very motivated to quit opioids before pregnancy, but 85% were very motivated to quit once pregnant. In the pre-survey, 76% incorrectly thought they would be reported to authorities by their health providers if they used illegal drugs during pregnancy, while in the post-survey, 100% knew they would not be reported for doing so. Also, all participants said learning more about the effects of opiates would increase motivation for sobriety.

Discussion

Questions assessed during the educational surveys revolved around patients’ knowledge of the intricacies, legally and physiologically, of methadone treatment for OUD, as well as beneficial aspects for patients and future child health, such as breastfeeding and motivation to quit and stay sober.

It was clear that there was a lack of knowledge and education about breastfeeding, as only 39% of the participants thought that it was safe to breastfeed while on methadone in the pre-survey; in the post survey, this improved to 97%. Students spent a large portion of the educational time going over the safety of breastfeeding for patients on methadone and the many benefits to mother and baby. Students also reviewed breastfeeding with patients every time patients came in for a visit and debunked any falsehoods about the negatives of breastfeeding while on methadone. This is another testament to the benefits of reinforcement around patient education.

The area of trust between provider and patient is essential in all provider-patient relationships. However, in the area of addiction, a trusting bond is especially important, as patients must feel confident and comfortable to disclose every aspect of their lives so the provider can give the best care. It was clear from our initial data that many patients did not feel this trust or understand the legal aspects regarding the provider-patient relationship in the terms of drug use, as the pre-survey shows 76% of patients originally thought they would be reported to authorities if they told their provider they used illegal drugs during pregnancy. This was an enormous issue in the clinic and something that needed to be addressed because, based on these data, we feared many patients would not be honest about using illegal drugs to supplement their methadone if they believed they would be reported to the authorities or even jailed. The medical student education team continually assured patients that their honesty about illegal drug use during pregnancy would not be revealed to the authorities, and also made it clear to patients that it was essential they were honest about illegal drug use so the optimal care could be provided by the team. These discussions were successful, as the post-survey showed that 100% of patients knew they would not be reported to the authorities if they used illegal drugs during the pregnancy. This showed an increase in knowledge, but also suggested an increase in confidence in the provider-patient relationship by patients, which we speculate allowed for a better patient experience, better patient outcomes, and less emotional stress for the patient and provider.

Last, we wanted to study and address the motivation to quit using drugs and stay sober through learning about the effects of opiates and how this motivation was related to pregnancy. A study by Mitchell et al makes clear that pregnancy is a motivation to seek treatment for drug use and to quit,²⁴ and our survey data support these findings, with 48% of patients motivated to quit before they were pregnant and 85% motivated to quit once they knew they were pregnant. In addition, all patients attested on the pre- and post-survey that learning more about opioids would increase their motivation for sobriety. Therefore, we believe education about the use of opioids and other drugs is a strong motivation towards sobriety and should be further studied in methadone treatment and other drugs as well.

We will continue to focus on sobriety postpartum by using the education in pregnancy as a springboard to further postpartum education, as education seems to be very beneficial to future sobriety. In the future, we believe extending the educational program past pregnancy and discussing opioid use and addiction with patients at multiple follow-up visits will be beneficial to patients’ sobriety.

We faced 2 main challenges in implementing this intervention and survey: patients would often miss multiple appointments during their third trimester or would not attend their postpartum visit if they only had 1 prenatal visit; and many clinic sessions had low student attendance because students often had many other responsibilities in medical school and there were only 15 volunteers over the study time. These challenges decreased our post-survey completion rate. However, there has been improvement in follow-up as the project has continued. The Mommies Program now has a full-time registered nurse, and a larger number of medical student teachers have volunteered to attend the clinic. In the future, we aim to increase awareness of our project and the benefits of participation, expand advertising at our medical school to increase student participation, and increase follow-up education in the postpartum period.

Another future direction is to include local, free doula services, which are offered through Catholic Charities in San Antonio. Doulas provide antepartum, intrapartum, and postpartum services, which we believe will help our patients through advocacy and support for sobriety during this emotional and stressful time.

Conclusion

Counseled participants were receptive to learning about the effects of OUD and methadone on themselves and their newborn. Participants unanimously stated that learning more about OUD increased their motivation for sobriety. It was also clear that the increased motivation to be sober during pregnancy, as compared to before pregnancy, is an opportunity to help these women take steps to get sober. Patients also advanced their breastfeeding knowledge, as we helped debunk falsehoods surrounding breastfeeding while on methadone, and we anticipate this will lead to greater breastfeeding rates for our patients on methadone, although this was not specifically studied. Finally, patients learned about patient-provider confidentiality, which allowed for more open and clear communication with patients so they could be cared for to the greatest degree and trust could remain paramount.

Drug use is a common problem in the health care system, and exposure to patients with addiction is important for medical students in training. We believe that attending the Mommies Program allowed medical students to gain exposure and skills to better help patients with OUD.

Corresponding author: Nicholas Stansbury, MD, [email protected].

Financial disclosures: None.

From the UT Health Long School of Medicine San Antonio, Texas.

Abstract

Objective: To educate pregnant patients with opioid use disorder (OUD) about the effects of opioids in order to improve understanding and help achieve sustained abstinence.

Methods: The Center for Health Care Services and University Hospital System (UHS) in San Antonio, TX, jointly operate a methadone clinic, the Mommies Program, for pregnant women with OUD. As part of this program, medical students discuss methadone use in pregnancy and the health effects of OUD on mother and child and review resources for sustained peripartum abstinence at prenatal visits with pregnant patients with OUD concurrently enrolled in the program. To evaluate the impact of this education intervention, students assessed patients’ knowledge of methadone effects on mother and baby, state laws concerning heroin and methadone use in pregnancy, and motivation to quit using opioids with pre- and post-intervention surveys.

Results: Of 68 women enrolled in the program, 33 completed both the pre-survey and the post-survey (48.5%). Nearly half (48%) were very motivated to quit before pregnancy, but 85% were very motivated to quit once pregnant. All participants said learning more about the effects of opiates would increase motivation for sobriety. Prior to the educational intervention, 39% of participants knew it was safe to breastfeed on methadone, which improved to 97% in the post-survey, and 76% incorrectly thought they would be reported to authorities by their health care providers if they used illegal drugs during pregnancy, while in the post-survey, 100% knew they would not be reported for doing so.

Conclusion: Pregnancy and education about opioids increased patients’ motivation to quit. Patients also advanced their breastfeeding knowledge and learned about patient-provider confidentiality. Our greatest challenge was participant follow-up; however, this improved with the help of a full-time Mommies Program nurse. Our future aim is to increase project awareness and extend the educational research.

Keywords: pregnancy; addiction; opioids; OUD; counseling.

In 2012 more than 259 million prescriptions for opioids were written in the United States, which was a 200% increase since 1998.¹ Since the early 2000s, admissions to opioid substance abuse programs and the death rate from opioids have quadrupled.^2-4 Specifically, the rate of heroin use increased more than 300% from 2010 to 2014.⁵ Opioid use in pregnancy has also escalated in recent years, with a 3- to 4-fold increase from 2000 to 2009 and with 4 in 1000 deliveries being complicated by opioid use disorder (OUD) in 2011.^6-8

Between 2000 and 2014, the maternal mortality rate in the United States increased 24%, making it the only industrialized nation with a maternal mortality rate that is rising rather than falling.⁹ The Texas Maternal Mortality and Morbidity Task Force found that between 2012 and 2015 drug overdose was the leading cause of maternal death in the period from delivery to 365 days postpartum, and it has increased dramatically since 2010.^10,11

In addition, maternal mortality reviews in several states have identified substance use as a major risk factor for pregnancy-associated deaths.^12,13 In Texas between 2012 and 2015, opioids were found in 58% of maternal drug overdoses.¹⁰ In 2007, 22.8% of women who were enrolled in Medicaid programs in 46 states filled an opioid prescription during pregnancy.¹⁴ Additionally, the rising prevalence of opioid use in pregnancy has led to a sharp increase in neonatal abstinence syndrome (NAS), rising from 1.5 cases per 1000 hospital births in 1999 to 6.0 per 1000 hospital births in 2013.¹⁵ Unsurprisingly, states with the highest rates of opioid prescribing also have the highest rates of NAS.¹⁶

Methadone combined with counseling and behavioral therapy has been the standard of care for the treatment of OUD in pregnancy since the 1970s. Methadone treatment prevents opioid withdrawal symptoms and increases adherence to prenatal care.¹⁷ One of the largest methadone treatment clinics in the San Antonio, TX, area is the Center for Health Care Services (CHCS). University Health System in San Antonio (UHS) has established a clinic called The Mommies Program, where mothers addicted to opioids can receive prenatal care by a dedicated physician, registered nurse, and a certified nurse midwife, who work in collaboration with the CHCS methadone clinic. Pregnant patients with OUD in pregnancy are concurrently enrolled in the Mommies Program and receive prenatal care through UHS and methadone treatment and counseling through CHCS. The continuity effort aims to increase prenatal care rates and adherence to methadone treatment.

Once mothers are off illicit opioids and on methadone, it is essential to discuss breastfeeding with them, as many mothers addicted to illicit opioids may have been told that they should not be breastfeeding. However, breastfeeding should be encouraged in women who are stable on methadone if they are not using illicit drugs and do not have other contraindications, regardless of maternal methadone dose, since the transfer of methadone into breast milk is minimal.^18-20 Breastfeeding is beneficial in women taking methadone and has been associated with decreased severity of NAS symptoms, decreased need for pharmacotherapy, and a shorter hospital stay for the baby.²¹ In addition, breastfeeding contributes to the development of an attachment between mother and infant, while also providing the infant with natural immunity. Women should be counseled about the need to stop breastfeeding in the event of a relapse.²²

Finally, the postpartum period represents a time of increased stressors, such as loss of sleep, child protective services involvement, and frustration with constant demands from new baby. For mothers with addiction, this is an especially sensitive time, as the stressors may be exacerbated by their new sobriety and a sudden end to the motivation they experienced from pregnancy.²³ Therefore, early and frequent postpartum care with methadone dose evaluation is essential in order to decrease drug relapse and screen for postpartum depression in detail, since patients with a history of drug use are at increased risk of postpartum depression.

In 2017 medical students at UT Health Long School of Medicine in San Antonio created a project to educate women about OUD in pregnancy and provide motivational incentives for sustained abstinence; this project has continued each year since. Students provide education about methadone treatment and the dangers of using illicit opioids during and after pregnancy. Students especially focus on educating patients on the key problem areas in the literature, such as overdose, NAS, breastfeeding, postpartum substance use, and postpartum depression.

Methods

From October 2018 to February 2020, a total of 15 medical students volunteered between 1 and 20 times at the Mommies Program clinic, which was held once or twice per week from 8 am to 12 pm. Prior to attending clinic, a fourth-year medical student oriented that year’s group of first-, second-, and third-year medical students who volunteered to attend the clinic. The orientation introduced students to the Mommies Program and instructed them on how and why methadone is prescribed and distributed. Students were also taught how to begin and proceed through each patient encounter, and were given a standard handout to review with patients. This handout made it possible for students of every level to attend the Mommies Program and ensured that the education was standardized at every session (Figure 1).

The only inclusion criteria for participating in the educational intervention and survey was participants had to be 18 years of age or older and enrolled in the Mommies Program. Patients who met the inclusion criteria and agreed to participate completed a pre-survey administered by the students during the patient’s initial prenatal visit (Figure 2). This survey collected baseline information about the patient’s history with opioid use and their current knowledge of methadone treatment, NAS, legal aspects of drug use disclosure, and drug testing prior to the education portion of the encounter. After the pre-survey was administered, students spent 30 minutes reviewing the correct answers of the survey with the patients by utilizing the standardized handout to help patients understand details of methadone and opioid use in pregnancy (Figure 1). The post-survey was administered by a student once patients entered the third trimester to assess whether the education session increased patients’ knowledge of these topics.

At the time patients completed the post-survey, they received a Baby Bag as well as education regarding each item in the bag. The aim of distributing Baby Bags was to relieve some possible postnatal stressors and educate the patients about infant care. Items included in the bag were diapers, wipes, bottles, clothes, and swaddles. Prenatal vitamins were added in January 2020, as many patients struggle to afford vitamins if they are not currently covered by Medicaid or have other barriers. The Baby Bag items were purchased through a Community Service Learning grant through UT Health San Antonio.

Results

Of 68 women enrolled in the Mommies Program during the intervention period, 33 completed the pre-survey and the post-survey (48.5%). Even though all patients enrolled in the program met the inclusion criteria, patients were not included in the educational program for multiple reasons, including refusal to participate, poor clinic follow-up, or lack of students to collect surveys. However, all patients who completed the pre-survey did complete the post-survey. In the pre-survey, only 39% of participants knew it was safe to breastfeed while on methadone. In the post-survey, 97% knew it safe to breastfeed. Nearly half (48%) reported being very motivated to quit opioids before pregnancy, but 85% were very motivated to quit once pregnant. In the pre-survey, 76% incorrectly thought they would be reported to authorities by their health providers if they used illegal drugs during pregnancy, while in the post-survey, 100% knew they would not be reported for doing so. Also, all participants said learning more about the effects of opiates would increase motivation for sobriety.

Discussion

Questions assessed during the educational surveys revolved around patients’ knowledge of the intricacies, legally and physiologically, of methadone treatment for OUD, as well as beneficial aspects for patients and future child health, such as breastfeeding and motivation to quit and stay sober.

It was clear that there was a lack of knowledge and education about breastfeeding, as only 39% of the participants thought that it was safe to breastfeed while on methadone in the pre-survey; in the post survey, this improved to 97%. Students spent a large portion of the educational time going over the safety of breastfeeding for patients on methadone and the many benefits to mother and baby. Students also reviewed breastfeeding with patients every time patients came in for a visit and debunked any falsehoods about the negatives of breastfeeding while on methadone. This is another testament to the benefits of reinforcement around patient education.

The area of trust between provider and patient is essential in all provider-patient relationships. However, in the area of addiction, a trusting bond is especially important, as patients must feel confident and comfortable to disclose every aspect of their lives so the provider can give the best care. It was clear from our initial data that many patients did not feel this trust or understand the legal aspects regarding the provider-patient relationship in the terms of drug use, as the pre-survey shows 76% of patients originally thought they would be reported to authorities if they told their provider they used illegal drugs during pregnancy. This was an enormous issue in the clinic and something that needed to be addressed because, based on these data, we feared many patients would not be honest about using illegal drugs to supplement their methadone if they believed they would be reported to the authorities or even jailed. The medical student education team continually assured patients that their honesty about illegal drug use during pregnancy would not be revealed to the authorities, and also made it clear to patients that it was essential they were honest about illegal drug use so the optimal care could be provided by the team. These discussions were successful, as the post-survey showed that 100% of patients knew they would not be reported to the authorities if they used illegal drugs during the pregnancy. This showed an increase in knowledge, but also suggested an increase in confidence in the provider-patient relationship by patients, which we speculate allowed for a better patient experience, better patient outcomes, and less emotional stress for the patient and provider.

Last, we wanted to study and address the motivation to quit using drugs and stay sober through learning about the effects of opiates and how this motivation was related to pregnancy. A study by Mitchell et al makes clear that pregnancy is a motivation to seek treatment for drug use and to quit,²⁴ and our survey data support these findings, with 48% of patients motivated to quit before they were pregnant and 85% motivated to quit once they knew they were pregnant. In addition, all patients attested on the pre- and post-survey that learning more about opioids would increase their motivation for sobriety. Therefore, we believe education about the use of opioids and other drugs is a strong motivation towards sobriety and should be further studied in methadone treatment and other drugs as well.

We will continue to focus on sobriety postpartum by using the education in pregnancy as a springboard to further postpartum education, as education seems to be very beneficial to future sobriety. In the future, we believe extending the educational program past pregnancy and discussing opioid use and addiction with patients at multiple follow-up visits will be beneficial to patients’ sobriety.

We faced 2 main challenges in implementing this intervention and survey: patients would often miss multiple appointments during their third trimester or would not attend their postpartum visit if they only had 1 prenatal visit; and many clinic sessions had low student attendance because students often had many other responsibilities in medical school and there were only 15 volunteers over the study time. These challenges decreased our post-survey completion rate. However, there has been improvement in follow-up as the project has continued. The Mommies Program now has a full-time registered nurse, and a larger number of medical student teachers have volunteered to attend the clinic. In the future, we aim to increase awareness of our project and the benefits of participation, expand advertising at our medical school to increase student participation, and increase follow-up education in the postpartum period.

Another future direction is to include local, free doula services, which are offered through Catholic Charities in San Antonio. Doulas provide antepartum, intrapartum, and postpartum services, which we believe will help our patients through advocacy and support for sobriety during this emotional and stressful time.

Conclusion

Counseled participants were receptive to learning about the effects of OUD and methadone on themselves and their newborn. Participants unanimously stated that learning more about OUD increased their motivation for sobriety. It was also clear that the increased motivation to be sober during pregnancy, as compared to before pregnancy, is an opportunity to help these women take steps to get sober. Patients also advanced their breastfeeding knowledge, as we helped debunk falsehoods surrounding breastfeeding while on methadone, and we anticipate this will lead to greater breastfeeding rates for our patients on methadone, although this was not specifically studied. Finally, patients learned about patient-provider confidentiality, which allowed for more open and clear communication with patients so they could be cared for to the greatest degree and trust could remain paramount.

Drug use is a common problem in the health care system, and exposure to patients with addiction is important for medical students in training. We believe that attending the Mommies Program allowed medical students to gain exposure and skills to better help patients with OUD.

Corresponding author: Nicholas Stansbury, MD, [email protected].

Financial disclosures: None.

From the UT Health Long School of Medicine San Antonio, Texas.

Abstract

Objective: To educate pregnant patients with opioid use disorder (OUD) about the effects of opioids in order to improve understanding and help achieve sustained abstinence.

Methods: The Center for Health Care Services and University Hospital System (UHS) in San Antonio, TX, jointly operate a methadone clinic, the Mommies Program, for pregnant women with OUD. As part of this program, medical students discuss methadone use in pregnancy and the health effects of OUD on mother and child and review resources for sustained peripartum abstinence at prenatal visits with pregnant patients with OUD concurrently enrolled in the program. To evaluate the impact of this education intervention, students assessed patients’ knowledge of methadone effects on mother and baby, state laws concerning heroin and methadone use in pregnancy, and motivation to quit using opioids with pre- and post-intervention surveys.

Results: Of 68 women enrolled in the program, 33 completed both the pre-survey and the post-survey (48.5%). Nearly half (48%) were very motivated to quit before pregnancy, but 85% were very motivated to quit once pregnant. All participants said learning more about the effects of opiates would increase motivation for sobriety. Prior to the educational intervention, 39% of participants knew it was safe to breastfeed on methadone, which improved to 97% in the post-survey, and 76% incorrectly thought they would be reported to authorities by their health care providers if they used illegal drugs during pregnancy, while in the post-survey, 100% knew they would not be reported for doing so.

Conclusion: Pregnancy and education about opioids increased patients’ motivation to quit. Patients also advanced their breastfeeding knowledge and learned about patient-provider confidentiality. Our greatest challenge was participant follow-up; however, this improved with the help of a full-time Mommies Program nurse. Our future aim is to increase project awareness and extend the educational research.

Keywords: pregnancy; addiction; opioids; OUD; counseling.

In 2012 more than 259 million prescriptions for opioids were written in the United States, which was a 200% increase since 1998.¹ Since the early 2000s, admissions to opioid substance abuse programs and the death rate from opioids have quadrupled.^2-4 Specifically, the rate of heroin use increased more than 300% from 2010 to 2014.⁵ Opioid use in pregnancy has also escalated in recent years, with a 3- to 4-fold increase from 2000 to 2009 and with 4 in 1000 deliveries being complicated by opioid use disorder (OUD) in 2011.^6-8

Between 2000 and 2014, the maternal mortality rate in the United States increased 24%, making it the only industrialized nation with a maternal mortality rate that is rising rather than falling.⁹ The Texas Maternal Mortality and Morbidity Task Force found that between 2012 and 2015 drug overdose was the leading cause of maternal death in the period from delivery to 365 days postpartum, and it has increased dramatically since 2010.^10,11

In addition, maternal mortality reviews in several states have identified substance use as a major risk factor for pregnancy-associated deaths.^12,13 In Texas between 2012 and 2015, opioids were found in 58% of maternal drug overdoses.¹⁰ In 2007, 22.8% of women who were enrolled in Medicaid programs in 46 states filled an opioid prescription during pregnancy.¹⁴ Additionally, the rising prevalence of opioid use in pregnancy has led to a sharp increase in neonatal abstinence syndrome (NAS), rising from 1.5 cases per 1000 hospital births in 1999 to 6.0 per 1000 hospital births in 2013.¹⁵ Unsurprisingly, states with the highest rates of opioid prescribing also have the highest rates of NAS.¹⁶

Methadone combined with counseling and behavioral therapy has been the standard of care for the treatment of OUD in pregnancy since the 1970s. Methadone treatment prevents opioid withdrawal symptoms and increases adherence to prenatal care.¹⁷ One of the largest methadone treatment clinics in the San Antonio, TX, area is the Center for Health Care Services (CHCS). University Health System in San Antonio (UHS) has established a clinic called The Mommies Program, where mothers addicted to opioids can receive prenatal care by a dedicated physician, registered nurse, and a certified nurse midwife, who work in collaboration with the CHCS methadone clinic. Pregnant patients with OUD in pregnancy are concurrently enrolled in the Mommies Program and receive prenatal care through UHS and methadone treatment and counseling through CHCS. The continuity effort aims to increase prenatal care rates and adherence to methadone treatment.

Once mothers are off illicit opioids and on methadone, it is essential to discuss breastfeeding with them, as many mothers addicted to illicit opioids may have been told that they should not be breastfeeding. However, breastfeeding should be encouraged in women who are stable on methadone if they are not using illicit drugs and do not have other contraindications, regardless of maternal methadone dose, since the transfer of methadone into breast milk is minimal.^18-20 Breastfeeding is beneficial in women taking methadone and has been associated with decreased severity of NAS symptoms, decreased need for pharmacotherapy, and a shorter hospital stay for the baby.²¹ In addition, breastfeeding contributes to the development of an attachment between mother and infant, while also providing the infant with natural immunity. Women should be counseled about the need to stop breastfeeding in the event of a relapse.²²

Finally, the postpartum period represents a time of increased stressors, such as loss of sleep, child protective services involvement, and frustration with constant demands from new baby. For mothers with addiction, this is an especially sensitive time, as the stressors may be exacerbated by their new sobriety and a sudden end to the motivation they experienced from pregnancy.²³ Therefore, early and frequent postpartum care with methadone dose evaluation is essential in order to decrease drug relapse and screen for postpartum depression in detail, since patients with a history of drug use are at increased risk of postpartum depression.

In 2017 medical students at UT Health Long School of Medicine in San Antonio created a project to educate women about OUD in pregnancy and provide motivational incentives for sustained abstinence; this project has continued each year since. Students provide education about methadone treatment and the dangers of using illicit opioids during and after pregnancy. Students especially focus on educating patients on the key problem areas in the literature, such as overdose, NAS, breastfeeding, postpartum substance use, and postpartum depression.

Methods

From October 2018 to February 2020, a total of 15 medical students volunteered between 1 and 20 times at the Mommies Program clinic, which was held once or twice per week from 8 am to 12 pm. Prior to attending clinic, a fourth-year medical student oriented that year’s group of first-, second-, and third-year medical students who volunteered to attend the clinic. The orientation introduced students to the Mommies Program and instructed them on how and why methadone is prescribed and distributed. Students were also taught how to begin and proceed through each patient encounter, and were given a standard handout to review with patients. This handout made it possible for students of every level to attend the Mommies Program and ensured that the education was standardized at every session (Figure 1).

The only inclusion criteria for participating in the educational intervention and survey was participants had to be 18 years of age or older and enrolled in the Mommies Program. Patients who met the inclusion criteria and agreed to participate completed a pre-survey administered by the students during the patient’s initial prenatal visit (Figure 2). This survey collected baseline information about the patient’s history with opioid use and their current knowledge of methadone treatment, NAS, legal aspects of drug use disclosure, and drug testing prior to the education portion of the encounter. After the pre-survey was administered, students spent 30 minutes reviewing the correct answers of the survey with the patients by utilizing the standardized handout to help patients understand details of methadone and opioid use in pregnancy (Figure 1). The post-survey was administered by a student once patients entered the third trimester to assess whether the education session increased patients’ knowledge of these topics.

At the time patients completed the post-survey, they received a Baby Bag as well as education regarding each item in the bag. The aim of distributing Baby Bags was to relieve some possible postnatal stressors and educate the patients about infant care. Items included in the bag were diapers, wipes, bottles, clothes, and swaddles. Prenatal vitamins were added in January 2020, as many patients struggle to afford vitamins if they are not currently covered by Medicaid or have other barriers. The Baby Bag items were purchased through a Community Service Learning grant through UT Health San Antonio.

Results

Of 68 women enrolled in the Mommies Program during the intervention period, 33 completed the pre-survey and the post-survey (48.5%). Even though all patients enrolled in the program met the inclusion criteria, patients were not included in the educational program for multiple reasons, including refusal to participate, poor clinic follow-up, or lack of students to collect surveys. However, all patients who completed the pre-survey did complete the post-survey. In the pre-survey, only 39% of participants knew it was safe to breastfeed while on methadone. In the post-survey, 97% knew it safe to breastfeed. Nearly half (48%) reported being very motivated to quit opioids before pregnancy, but 85% were very motivated to quit once pregnant. In the pre-survey, 76% incorrectly thought they would be reported to authorities by their health providers if they used illegal drugs during pregnancy, while in the post-survey, 100% knew they would not be reported for doing so. Also, all participants said learning more about the effects of opiates would increase motivation for sobriety.

Discussion

Questions assessed during the educational surveys revolved around patients’ knowledge of the intricacies, legally and physiologically, of methadone treatment for OUD, as well as beneficial aspects for patients and future child health, such as breastfeeding and motivation to quit and stay sober.

It was clear that there was a lack of knowledge and education about breastfeeding, as only 39% of the participants thought that it was safe to breastfeed while on methadone in the pre-survey; in the post survey, this improved to 97%. Students spent a large portion of the educational time going over the safety of breastfeeding for patients on methadone and the many benefits to mother and baby. Students also reviewed breastfeeding with patients every time patients came in for a visit and debunked any falsehoods about the negatives of breastfeeding while on methadone. This is another testament to the benefits of reinforcement around patient education.

The area of trust between provider and patient is essential in all provider-patient relationships. However, in the area of addiction, a trusting bond is especially important, as patients must feel confident and comfortable to disclose every aspect of their lives so the provider can give the best care. It was clear from our initial data that many patients did not feel this trust or understand the legal aspects regarding the provider-patient relationship in the terms of drug use, as the pre-survey shows 76% of patients originally thought they would be reported to authorities if they told their provider they used illegal drugs during pregnancy. This was an enormous issue in the clinic and something that needed to be addressed because, based on these data, we feared many patients would not be honest about using illegal drugs to supplement their methadone if they believed they would be reported to the authorities or even jailed. The medical student education team continually assured patients that their honesty about illegal drug use during pregnancy would not be revealed to the authorities, and also made it clear to patients that it was essential they were honest about illegal drug use so the optimal care could be provided by the team. These discussions were successful, as the post-survey showed that 100% of patients knew they would not be reported to the authorities if they used illegal drugs during the pregnancy. This showed an increase in knowledge, but also suggested an increase in confidence in the provider-patient relationship by patients, which we speculate allowed for a better patient experience, better patient outcomes, and less emotional stress for the patient and provider.

Last, we wanted to study and address the motivation to quit using drugs and stay sober through learning about the effects of opiates and how this motivation was related to pregnancy. A study by Mitchell et al makes clear that pregnancy is a motivation to seek treatment for drug use and to quit,²⁴ and our survey data support these findings, with 48% of patients motivated to quit before they were pregnant and 85% motivated to quit once they knew they were pregnant. In addition, all patients attested on the pre- and post-survey that learning more about opioids would increase their motivation for sobriety. Therefore, we believe education about the use of opioids and other drugs is a strong motivation towards sobriety and should be further studied in methadone treatment and other drugs as well.

We will continue to focus on sobriety postpartum by using the education in pregnancy as a springboard to further postpartum education, as education seems to be very beneficial to future sobriety. In the future, we believe extending the educational program past pregnancy and discussing opioid use and addiction with patients at multiple follow-up visits will be beneficial to patients’ sobriety.

We faced 2 main challenges in implementing this intervention and survey: patients would often miss multiple appointments during their third trimester or would not attend their postpartum visit if they only had 1 prenatal visit; and many clinic sessions had low student attendance because students often had many other responsibilities in medical school and there were only 15 volunteers over the study time. These challenges decreased our post-survey completion rate. However, there has been improvement in follow-up as the project has continued. The Mommies Program now has a full-time registered nurse, and a larger number of medical student teachers have volunteered to attend the clinic. In the future, we aim to increase awareness of our project and the benefits of participation, expand advertising at our medical school to increase student participation, and increase follow-up education in the postpartum period.

Another future direction is to include local, free doula services, which are offered through Catholic Charities in San Antonio. Doulas provide antepartum, intrapartum, and postpartum services, which we believe will help our patients through advocacy and support for sobriety during this emotional and stressful time.

Conclusion

Counseled participants were receptive to learning about the effects of OUD and methadone on themselves and their newborn. Participants unanimously stated that learning more about OUD increased their motivation for sobriety. It was also clear that the increased motivation to be sober during pregnancy, as compared to before pregnancy, is an opportunity to help these women take steps to get sober. Patients also advanced their breastfeeding knowledge, as we helped debunk falsehoods surrounding breastfeeding while on methadone, and we anticipate this will lead to greater breastfeeding rates for our patients on methadone, although this was not specifically studied. Finally, patients learned about patient-provider confidentiality, which allowed for more open and clear communication with patients so they could be cared for to the greatest degree and trust could remain paramount.

Drug use is a common problem in the health care system, and exposure to patients with addiction is important for medical students in training. We believe that attending the Mommies Program allowed medical students to gain exposure and skills to better help patients with OUD.

Corresponding author: Nicholas Stansbury, MD, [email protected].

Financial disclosures: None.

OBG Management takes the issues of systemic and structural racism incredibly seriously--not just by talking about it but by trying to highlight areas in medicine, particularly in obstetrics and gynecology, that are barriers to progress. In this new series for OBG Management, Board Member Barbara Levy, MD, faces the issues head-on, beginning with this peer-to-peer interview with Pierre Johnson, MD, ObGyn in Chicago, Illinois. Watch for future installments in upcoming issues of OBG Management.

Finding inspiration among life’s challenges

Barbara Levy, MD: I am fortunate to have met Pierre serendipitously at a training that we were both attending and was impressed by Dr. Johnson’s life story, his passion and commitment, and his dedication—not only to his personal career but also to raising up other young men of color by trying to break down barriers that face them. His life story highlights those areas of systemic and structural problems that all of us together need to address if we are going to make any progress.

Pierre Johnson, MD: Thank you, Barbara. A little about myself: I am a board-certified ObGyn, and I specialize in minimally invasive surgery. I was born on the South side of Chicago, experiencing gang violence, drugs, and substandard, underserved schools. Long story short, I had a very rough upbringing. I had a single mom and several different issues at home. I am the oldest of 5 siblings, and life was tough.

But I knew that I wanted to do something different with my life. I saw that there was a need in my community as far as health care was concerned, in particular women’s health and childbirth. I knew early on that I wanted to be an ObGyn, and the reason had a lot to do with The Cosby Show. It was the only example of a positive, successful Black man that I saw. No one graduated from college in my family. There weren’t any models of young Black excellence around me. Saying that I wanted to be a doctor planted a seed. I was 9 when my mom became pregnant with my first sibling, and it was fascinating to me. The physiology of pregnancy, and eventually childbirth, was extremely fascinating to me; it set me off on my journey to be an ObGyn.

As I got older, things didn’t get any easier. I went to high school in one of the toughest areas on the South side of Chicago. Gang violence, and violence in and of itself, were all around me, but I was able to stay focused. I went on to Xavier University in Louisiana.

Dr. Levy: There are some important things that I learned from your book and from talking to you at our first meeting. Your mom’s ObGyn, when she was pregnant with your next youngest sibling, was also a Black ObGyn. He took some time to take you under wing?

Dr. Johnson: He did. My mom’s ObGyn was a Black man. Other than The Cosby Show, that’s the only time I saw something like that. When I spoke to him, he really took the time to answer my questions and show me that he was like me; he wasn’t just a far-off mythical person, or something that I could not obtain.

Continue to: Seeing is believing when it comes to success...

Seeing is believing when it comes to success

Dr. Levy: Do you think it was important to have a role model who wasn’t a sports star?

Dr. Johnson: If you can’t see it, you can’t achieve it. He took his time to really talk to me, and it’s the little things for kids that go a long way in their life experience. I still have a relationship with him to this day. How he handled me as a kid made me realize that this is something that I could do. That was extremely important for me.

Dr. Levy: One of the structural things I think we need to point out is that the ability to see yourself as someone successful is critical. When we see 1,000 images a day and they are all White, and they are all so different from where we are that it gets incorporated into our sense of being. I think that’s really difficult for those of us of with privilege to understand what that privilege is.

Dr. Johnson: Absolutely, and I’ll even go further. In residency, 2 White females were my classmates, and both of their parents were doctors. They had grandparents who were doctors. My mom was addicted to drugs; my father was not around. They had been talking medicine since they were 5. You have to make things equitable, but in medicine it’s really not equitable. In medicine, what we don’t realize is that there is an importance for all aspects of someone’s upbringing and environment, and it’s not just what they can regurgitate on a standardized test. If a patient can’t relate to you and tell you what is wrong with them, how can you adequately treat them?

Dr. Levy: Even if they are trying to tell me, but I can’t hear it because I don’t have the language and I don’t have the background. There are really good data to show, in fact, that Black male physicians do a better job at engaging Black men to manage their hypertension.¹ When we look at the inequities in birth outcomes for women of color, indigenous women and Black women, there’s evidence that providers who come from a similar background do a better job.

Dr. Johnson: There was the study of Black infants that just came out about them dying at a 3-time higher rate in non-Black physicians’ hands.² These things need to be recognized. They need to be discussed, and they need to be identified as issues and then, realistically, we need to start talking about solutions, not get offended by what actual statistics are saying.

Foundational inequities in education

Dr. Levy: To address some of the barriers that you faced: I know that you went to a high school that was not geared toward pushing students into professional careers. Your colleagues, however, had educations that prepared them for the standardized tests and other things that they would face academically.

Dr. Johnson: People think I am kidding when I say it, but when I went into college, I didn’t know what a periodic table was. I saw it, but I had no idea what these things meant. I didn’t have any sciences or any AP classes in high school. I did well, but grades are smoke and mirrors. The true test of medicine comes with testing. From the MCATs to the boards, every step of the way there is a standardized test.

Knowledge is something that you can obtain, but test taking is a cultivated skill that happens from a very early age. Trying to teach an adult or someone in their late teens a skill that they should have learned as a kid is difficult. For me, I did not have that, so I had to program myself. I had to learn how to fundamentally take tests as an adult, where most people understand how to do that going into college and professional school.

Dr. Levy: I was impressed with your resilience. I think all of us as human beings, if we fail a test, we take it personally and think it’s about our lack of knowledge. One of the insights that you came to was that failure on those things was not that you didn’t study hard enough. In fact, you probably studied 4 times harder than most other people. You had the knowledge. Being able to get that knowledge into a standardized structured test score was the huge challenge for you.

Dr. Johnson: That’s it. I can remember taking the MCAT, and if you looked at the step 1 book, I could regurgitate to you everything on that page. However, it’s not a test about do you know it or not. It’s an understanding of the English language and how to break things down to make things fit into particular scenarios.

Continue to: A college experience focused on growth and exposure...

 

 

A college experience focused on growth and exposure

Dr. Levy: I was impressed by the distinction between your experience at Xavier University where there was a lot of support and guidance and help in your premed program, and what happened to you when you hit medical school.

Dr. Johnson: Xavier University in Louisiana is the number 1 institution in the country for getting minorities into professional school. They understand that they have kids that are brilliant but underprepared, and just have not had the background to actually tackle some of these tough curriculums. I always had good grades in school. But by not being challenged, I didn’t know what I didn’t really know. So now that I was seeing biology, chemistry for the first time, and trying to tackle it; there’s a failure point. I didn’t know how to take tests, and I didn’t know how to study properly. The harder I tried, the worse things got for me.

Xavier has seen that story a multitude of times. If I went to a bigger or predominantly White university, a counselor would have told me, “Well, medicine’s maybe not for you. You can’t handle a premed curriculum.” Instead, I said, “Listen, I’m studying. I’m doing all of these things, and I’m not hacking it.” And they broke it down: “Let’s get you into study groups with kids that have had these type of AP classes before. We’ll have you watch how they study,” and everything started to click. That facilitation of how to adjust to this curriculum was a godsend. It’s the only reason I’m here. I am a prime example of being brilliant enough to be able to do it, but needing the infrastructure and a system set up.

Dr. Levy: There’s a great book by Carol Dweck called Mindset that talks about education of young kids and putting them into silos so early in life; the brilliant kids go into the AP courses and the rest are labeled as inadequate. It’s assumed in a fixed mindset based on their heredity and IQ, and not based on the fact that they have not been exposed to the right things.

Xavier was growing you into the man who could, in fact, do all of those things. I think that is one of the systemic and structural issues that we have—that fixed mindset that frames a kid who is not succeeding as therefore unable to succeed, as opposed to framing that child as not having the correct tools.

New tribulations of medical school

Dr. Johnson: Absolutely. I think what Xavier did for me is to at least let me understand what I needed to do, how to comprehend and retain information, which I never had been exposed to before. Those years were very important to establishing a foundation. When going to medical school, it was like, “There’s no more excuses. What could be the problem now?” Well, now let’s talk about taking tests—a whole different skill. Xavier focused on getting me to understand how to structure my thought process and knowledge base. In medical school I had to apply those skills (because if you can’t apply them, there’s no fit).

My second through fourth year of medical school, I was the only African-American kid in my class. I was spending 20-hour days sometimes just studying, trying to overcompensate by knowing as much as I possibly could and thinking that would propel me from the test-taking standpoint. Even though I didn’t have a lot of classmates in medical school that looked like me, I did have mentors that looked similarly, who really saw potential in me. Dr. Frederick Horvath, a nephrologist in Peoria said, “What are you doing? I want you to get out of these books, and let’s go out to lunch.”

He ended up buying me some instrumental books, really talked to me, listening to my background and understanding how driven I was as a person. He took me under his wing for the rest of medical school and said, “This is how you navigate through these spaces. Yes, you need to have a fund of knowledge to be able to take these tests, but you need to start understanding how to apply it to these questions.” I’m forever grateful to Dr. Horvath for doing that because it was a point in time where I was lost and struggling.

Continue to: Hitting a stride but facing racism head-on...

 

 

Hitting a stride but facing racism head-on

Dr. Levy: You talk about the systemic and pervasive racism that was on the wards when you hit them in fourth year. If you don’t mind sharing just a little bit of that, it would help people reading this to have a better understanding of the kinds of barriers that are out there.

Dr. Johnson: Even when I talk about it today, it bothers me.

I went to medical school in Peoria, Illinois, not far from the home of the Ku Klux Klan. At that time, once you got out of Chicago it was a very brutal place, with systemic racism throughout. I was a young Black kid going through a process that not many young Black kids from the South side of Chicago go through, and you had people who had never seen anyone like me. When I was going through my clinical rotations, I knew what I was up against. I was dressed “to the T” every day, arriving early, leaving late, trying to answer questions. I would look at the evaluations, and they would be disparaging. I would look at my counterparts, how their evaluations were, and how people would respond to them, and it would be completely different.

Surgery was the part of ObGyn that I really grew to love more than anything, even more than obstetrics. When general surgery came, I wanted to take it very seriously and learn as much as I possibly could. From the beginning, I knew there was a problem because the chief resident, an older White man, wouldn’t look me in the eye or talk to me. He would make disparaging remarks. The thing that stuck out in my mind the most was when I was in the operating room transporting patients, just like a medical student did, and he came up behind me and said, “You know, Pierre, this is where a small mind and a strong back come into play.” For me, it took me to a place where I had to corral my emotions and thoughts because I just wanted to lash out and just tell him how racist and horrible that was for him to say that to me. I explained this to the powers that be, the director of the department, and they basically blew it off to the side.

When it came down to the end of the evaluation period, I passed with flying colors. But they gave me an incomplete because of that chief resident and his remarks on my evaluations. He had 3 pages of report about me as a person and as a student. He said that he had difficulty in expressing his opinions about me because of possible cultural biases that he may have had. He put “cultural biases” in an evaluation, and they looked at that and said that was enough for me to have to remediate my time. I was required to do an extra month in Pontiac, Illinois, which is even more rural than Peoria, because of a racist person that did not give me a fair opportunity because I was Black.

Like everything else in life, it was a learning experience. It’s why I fight so hard today. It’s why I’m so passionate about equity, not only in medicine but also in all aspects of society. It shows why we have police brutality and Black men dying in the streets. It shows how this happens because there are cultural and implicit biases that play out in every part of life, and we are not honest about it. Until we are honest about it and until we say that this is happening and there is something that needs to be done to address it, it’s going to continue to happen. That is my fight.

Exposing the unspoken power struggle

Dr. Levy: I couldn’t agree more. Attributing things like that to the individual, where you talk about a White man in power and a power structure that didn’t literally physically beat you but did beat you into submission. You talk about how to succeed in medical school, and how you had to suck it up and submit to something that was incredibly unfair. You understood, you were old enough, mature enough, to understand that if you fought back, you were going to lose. The only opportunity you had was to submit to that inequity and push forward.

Dr. Johnson: When I did try to fight, the chair of the department told me that either I accept the consequences or I would not graduate from medical school and be forced to do another year. That struck a chord with me. I think that happens a lot in our society, and it needs to be exposed.

Past experiences reflected in today’s society

Dr. Levy: Can you talk about what you faced in your ObGyn residency in terms of the systemic pushback, people not taking your orders, people questioning you. I know that I have heard that a great deal, and I experienced that myself as a woman.

Dr. Johnson: We look at the things that are happening now, everything from George Floyd’s murder to Colin Kaepernick taking a knee. These things are 10 years past when I first started residency. The year before I started residency, there was a noose hanging on the capitol lawn of Springfield, Illinois’ capital city. There’s systemic racism and hatred there. When I first started on the wards of my first year of ObGyn, again, I was the very first Black resident of my program’s history. Nobody could relate to me.

I went from a year-long general surgery internship at Washington Hospital Center in Washington, DC, to ObGyn residency. In the first 2 months, there were complaints of, “He’s not answering his pages. He’s not being prompt.” I went to my program director and said, “Listen, I have never had one complaint like this. There’s a problem here. And there’s a problem when I’m on the floor: When trying to give orders to nurses, they’re not taking them. I had to tell a couple of nurses, ‘I’m Dr. Johnson. Don’t call me by my first name, especially not in front of patients.’”

My director was just not hearing me, because the entire scenario was something they had never been exposed to. Systemic racism is real, and unless you experience it, it’s very difficult to accept that it is happening. But biases happen when you are not cognizant. People are used to things a certain way. Things play out in the media that make your mind think a certain way, and you don’t even realize it. You may not even want to be that way.

Continue to: Unconscious bias is a barrier to ensuring equity...

 

 

Unconscious bias is a barrier to ensuring equity

Dr. Levy: One very important point you just made is that we as the system need to be able to recognize those unconscious things, the language that we use, the disparaging remarks, the things that put people down, as well as the things that keep people out of promotion.

There are some interesting data about both race and gender and the language that we use when we write recommendations for people, that we do things unconsciously. The big message to all of us at the end is to open our minds to where those things can occur. For myself, professionally, I keep a list of words that I use when I write recommendations. I measure myself to ensure that I am using the same language for men and women, for Black and White. I think we need to overcome the system and the structure to create real equity—not equality but equity.

It begins with being real about the issues

Dr. Johnson: It’s a bigger problem than the existence of bias and racism. I think these are systemic issues that have been cultivated over centuries that have never been addressed. The true issue is that we deny that these are problems and refuse to talk about it because it makes us uncomfortable. To truly make things more equitable, we have to push our levels of comfort to be able to talk about things in a healthy manner, be open and transparent, and to start to understand how we are thinking about certain things. When you can see it, you can start to implement changes and start to change mentalities and thought processes.

For me, people say, “You don’t look like a doctor.” I get that all the time—because I have tattoos and earrings. I wear my hair in a mohawk. The image of what success looks like has been manifested through our media and culture, and it has imprinted on our minds as to how things are supposed to be. If someone doesn’t fit those molds, we start to shun them out, or we start to exhibit biases against those things. What I am trying to do is change that thought process of what a successful or a professional person looks like. It doesn’t have a look. It is not a White or Black thing. It’s an intellect, a mindset, a way of living. You have to treat every person as an individual and take all the biases out of it and understand where they are coming from and what they have to offer to the profession.

Dr. Levy: I personally was so impressed by you when I met you. I was impressed by the tattoos and the earrings, and my initial response to them was exactly that biased, “Oh, who is this person?” I checked that at the door, listened to you, and was really impressed at your surgical skill, your knowledge, your background. I am really grateful that you have been willing to spend the time to share that with everyone.

Dr. Johnson: Thank you for this discussion.

To watch the full interview between Drs. Levy and Johnson, visit: https://www.mdedge.com/obgyn/article/228507/facing-systemic-racism-health-care-inequities-medical-education. ●

OBG Management takes the issues of systemic and structural racism incredibly seriously--not just by talking about it but by trying to highlight areas in medicine, particularly in obstetrics and gynecology, that are barriers to progress. In this new series for OBG Management, Board Member Barbara Levy, MD, faces the issues head-on, beginning with this peer-to-peer interview with Pierre Johnson, MD, ObGyn in Chicago, Illinois. Watch for future installments in upcoming issues of OBG Management.

Finding inspiration among life’s challenges

Barbara Levy, MD: I am fortunate to have met Pierre serendipitously at a training that we were both attending and was impressed by Dr. Johnson’s life story, his passion and commitment, and his dedication—not only to his personal career but also to raising up other young men of color by trying to break down barriers that face them. His life story highlights those areas of systemic and structural problems that all of us together need to address if we are going to make any progress.

Pierre Johnson, MD: Thank you, Barbara. A little about myself: I am a board-certified ObGyn, and I specialize in minimally invasive surgery. I was born on the South side of Chicago, experiencing gang violence, drugs, and substandard, underserved schools. Long story short, I had a very rough upbringing. I had a single mom and several different issues at home. I am the oldest of 5 siblings, and life was tough.

But I knew that I wanted to do something different with my life. I saw that there was a need in my community as far as health care was concerned, in particular women’s health and childbirth. I knew early on that I wanted to be an ObGyn, and the reason had a lot to do with The Cosby Show. It was the only example of a positive, successful Black man that I saw. No one graduated from college in my family. There weren’t any models of young Black excellence around me. Saying that I wanted to be a doctor planted a seed. I was 9 when my mom became pregnant with my first sibling, and it was fascinating to me. The physiology of pregnancy, and eventually childbirth, was extremely fascinating to me; it set me off on my journey to be an ObGyn.

As I got older, things didn’t get any easier. I went to high school in one of the toughest areas on the South side of Chicago. Gang violence, and violence in and of itself, were all around me, but I was able to stay focused. I went on to Xavier University in Louisiana.

Dr. Levy: There are some important things that I learned from your book and from talking to you at our first meeting. Your mom’s ObGyn, when she was pregnant with your next youngest sibling, was also a Black ObGyn. He took some time to take you under wing?

Dr. Johnson: He did. My mom’s ObGyn was a Black man. Other than The Cosby Show, that’s the only time I saw something like that. When I spoke to him, he really took the time to answer my questions and show me that he was like me; he wasn’t just a far-off mythical person, or something that I could not obtain.

Continue to: Seeing is believing when it comes to success...

Seeing is believing when it comes to success

Dr. Levy: Do you think it was important to have a role model who wasn’t a sports star?

Dr. Johnson: If you can’t see it, you can’t achieve it. He took his time to really talk to me, and it’s the little things for kids that go a long way in their life experience. I still have a relationship with him to this day. How he handled me as a kid made me realize that this is something that I could do. That was extremely important for me.

Dr. Levy: One of the structural things I think we need to point out is that the ability to see yourself as someone successful is critical. When we see 1,000 images a day and they are all White, and they are all so different from where we are that it gets incorporated into our sense of being. I think that’s really difficult for those of us of with privilege to understand what that privilege is.

Dr. Johnson: Absolutely, and I’ll even go further. In residency, 2 White females were my classmates, and both of their parents were doctors. They had grandparents who were doctors. My mom was addicted to drugs; my father was not around. They had been talking medicine since they were 5. You have to make things equitable, but in medicine it’s really not equitable. In medicine, what we don’t realize is that there is an importance for all aspects of someone’s upbringing and environment, and it’s not just what they can regurgitate on a standardized test. If a patient can’t relate to you and tell you what is wrong with them, how can you adequately treat them?

Dr. Levy: Even if they are trying to tell me, but I can’t hear it because I don’t have the language and I don’t have the background. There are really good data to show, in fact, that Black male physicians do a better job at engaging Black men to manage their hypertension.¹ When we look at the inequities in birth outcomes for women of color, indigenous women and Black women, there’s evidence that providers who come from a similar background do a better job.

Dr. Johnson: There was the study of Black infants that just came out about them dying at a 3-time higher rate in non-Black physicians’ hands.² These things need to be recognized. They need to be discussed, and they need to be identified as issues and then, realistically, we need to start talking about solutions, not get offended by what actual statistics are saying.

Foundational inequities in education

Dr. Levy: To address some of the barriers that you faced: I know that you went to a high school that was not geared toward pushing students into professional careers. Your colleagues, however, had educations that prepared them for the standardized tests and other things that they would face academically.

Dr. Johnson: People think I am kidding when I say it, but when I went into college, I didn’t know what a periodic table was. I saw it, but I had no idea what these things meant. I didn’t have any sciences or any AP classes in high school. I did well, but grades are smoke and mirrors. The true test of medicine comes with testing. From the MCATs to the boards, every step of the way there is a standardized test.

Knowledge is something that you can obtain, but test taking is a cultivated skill that happens from a very early age. Trying to teach an adult or someone in their late teens a skill that they should have learned as a kid is difficult. For me, I did not have that, so I had to program myself. I had to learn how to fundamentally take tests as an adult, where most people understand how to do that going into college and professional school.

Dr. Levy: I was impressed with your resilience. I think all of us as human beings, if we fail a test, we take it personally and think it’s about our lack of knowledge. One of the insights that you came to was that failure on those things was not that you didn’t study hard enough. In fact, you probably studied 4 times harder than most other people. You had the knowledge. Being able to get that knowledge into a standardized structured test score was the huge challenge for you.

Dr. Johnson: That’s it. I can remember taking the MCAT, and if you looked at the step 1 book, I could regurgitate to you everything on that page. However, it’s not a test about do you know it or not. It’s an understanding of the English language and how to break things down to make things fit into particular scenarios.

Continue to: A college experience focused on growth and exposure...

 

 

A college experience focused on growth and exposure

Dr. Levy: I was impressed by the distinction between your experience at Xavier University where there was a lot of support and guidance and help in your premed program, and what happened to you when you hit medical school.

Dr. Johnson: Xavier University in Louisiana is the number 1 institution in the country for getting minorities into professional school. They understand that they have kids that are brilliant but underprepared, and just have not had the background to actually tackle some of these tough curriculums. I always had good grades in school. But by not being challenged, I didn’t know what I didn’t really know. So now that I was seeing biology, chemistry for the first time, and trying to tackle it; there’s a failure point. I didn’t know how to take tests, and I didn’t know how to study properly. The harder I tried, the worse things got for me.

Xavier has seen that story a multitude of times. If I went to a bigger or predominantly White university, a counselor would have told me, “Well, medicine’s maybe not for you. You can’t handle a premed curriculum.” Instead, I said, “Listen, I’m studying. I’m doing all of these things, and I’m not hacking it.” And they broke it down: “Let’s get you into study groups with kids that have had these type of AP classes before. We’ll have you watch how they study,” and everything started to click. That facilitation of how to adjust to this curriculum was a godsend. It’s the only reason I’m here. I am a prime example of being brilliant enough to be able to do it, but needing the infrastructure and a system set up.

Dr. Levy: There’s a great book by Carol Dweck called Mindset that talks about education of young kids and putting them into silos so early in life; the brilliant kids go into the AP courses and the rest are labeled as inadequate. It’s assumed in a fixed mindset based on their heredity and IQ, and not based on the fact that they have not been exposed to the right things.

Xavier was growing you into the man who could, in fact, do all of those things. I think that is one of the systemic and structural issues that we have—that fixed mindset that frames a kid who is not succeeding as therefore unable to succeed, as opposed to framing that child as not having the correct tools.

New tribulations of medical school

Dr. Johnson: Absolutely. I think what Xavier did for me is to at least let me understand what I needed to do, how to comprehend and retain information, which I never had been exposed to before. Those years were very important to establishing a foundation. When going to medical school, it was like, “There’s no more excuses. What could be the problem now?” Well, now let’s talk about taking tests—a whole different skill. Xavier focused on getting me to understand how to structure my thought process and knowledge base. In medical school I had to apply those skills (because if you can’t apply them, there’s no fit).

My second through fourth year of medical school, I was the only African-American kid in my class. I was spending 20-hour days sometimes just studying, trying to overcompensate by knowing as much as I possibly could and thinking that would propel me from the test-taking standpoint. Even though I didn’t have a lot of classmates in medical school that looked like me, I did have mentors that looked similarly, who really saw potential in me. Dr. Frederick Horvath, a nephrologist in Peoria said, “What are you doing? I want you to get out of these books, and let’s go out to lunch.”

He ended up buying me some instrumental books, really talked to me, listening to my background and understanding how driven I was as a person. He took me under his wing for the rest of medical school and said, “This is how you navigate through these spaces. Yes, you need to have a fund of knowledge to be able to take these tests, but you need to start understanding how to apply it to these questions.” I’m forever grateful to Dr. Horvath for doing that because it was a point in time where I was lost and struggling.

Continue to: Hitting a stride but facing racism head-on...

 

 

Hitting a stride but facing racism head-on

Dr. Levy: You talk about the systemic and pervasive racism that was on the wards when you hit them in fourth year. If you don’t mind sharing just a little bit of that, it would help people reading this to have a better understanding of the kinds of barriers that are out there.

Dr. Johnson: Even when I talk about it today, it bothers me.

I went to medical school in Peoria, Illinois, not far from the home of the Ku Klux Klan. At that time, once you got out of Chicago it was a very brutal place, with systemic racism throughout. I was a young Black kid going through a process that not many young Black kids from the South side of Chicago go through, and you had people who had never seen anyone like me. When I was going through my clinical rotations, I knew what I was up against. I was dressed “to the T” every day, arriving early, leaving late, trying to answer questions. I would look at the evaluations, and they would be disparaging. I would look at my counterparts, how their evaluations were, and how people would respond to them, and it would be completely different.

Surgery was the part of ObGyn that I really grew to love more than anything, even more than obstetrics. When general surgery came, I wanted to take it very seriously and learn as much as I possibly could. From the beginning, I knew there was a problem because the chief resident, an older White man, wouldn’t look me in the eye or talk to me. He would make disparaging remarks. The thing that stuck out in my mind the most was when I was in the operating room transporting patients, just like a medical student did, and he came up behind me and said, “You know, Pierre, this is where a small mind and a strong back come into play.” For me, it took me to a place where I had to corral my emotions and thoughts because I just wanted to lash out and just tell him how racist and horrible that was for him to say that to me. I explained this to the powers that be, the director of the department, and they basically blew it off to the side.

When it came down to the end of the evaluation period, I passed with flying colors. But they gave me an incomplete because of that chief resident and his remarks on my evaluations. He had 3 pages of report about me as a person and as a student. He said that he had difficulty in expressing his opinions about me because of possible cultural biases that he may have had. He put “cultural biases” in an evaluation, and they looked at that and said that was enough for me to have to remediate my time. I was required to do an extra month in Pontiac, Illinois, which is even more rural than Peoria, because of a racist person that did not give me a fair opportunity because I was Black.

Like everything else in life, it was a learning experience. It’s why I fight so hard today. It’s why I’m so passionate about equity, not only in medicine but also in all aspects of society. It shows why we have police brutality and Black men dying in the streets. It shows how this happens because there are cultural and implicit biases that play out in every part of life, and we are not honest about it. Until we are honest about it and until we say that this is happening and there is something that needs to be done to address it, it’s going to continue to happen. That is my fight.

Exposing the unspoken power struggle

Dr. Levy: I couldn’t agree more. Attributing things like that to the individual, where you talk about a White man in power and a power structure that didn’t literally physically beat you but did beat you into submission. You talk about how to succeed in medical school, and how you had to suck it up and submit to something that was incredibly unfair. You understood, you were old enough, mature enough, to understand that if you fought back, you were going to lose. The only opportunity you had was to submit to that inequity and push forward.

Dr. Johnson: When I did try to fight, the chair of the department told me that either I accept the consequences or I would not graduate from medical school and be forced to do another year. That struck a chord with me. I think that happens a lot in our society, and it needs to be exposed.

Past experiences reflected in today’s society

Dr. Levy: Can you talk about what you faced in your ObGyn residency in terms of the systemic pushback, people not taking your orders, people questioning you. I know that I have heard that a great deal, and I experienced that myself as a woman.

Dr. Johnson: We look at the things that are happening now, everything from George Floyd’s murder to Colin Kaepernick taking a knee. These things are 10 years past when I first started residency. The year before I started residency, there was a noose hanging on the capitol lawn of Springfield, Illinois’ capital city. There’s systemic racism and hatred there. When I first started on the wards of my first year of ObGyn, again, I was the very first Black resident of my program’s history. Nobody could relate to me.

I went from a year-long general surgery internship at Washington Hospital Center in Washington, DC, to ObGyn residency. In the first 2 months, there were complaints of, “He’s not answering his pages. He’s not being prompt.” I went to my program director and said, “Listen, I have never had one complaint like this. There’s a problem here. And there’s a problem when I’m on the floor: When trying to give orders to nurses, they’re not taking them. I had to tell a couple of nurses, ‘I’m Dr. Johnson. Don’t call me by my first name, especially not in front of patients.’”

My director was just not hearing me, because the entire scenario was something they had never been exposed to. Systemic racism is real, and unless you experience it, it’s very difficult to accept that it is happening. But biases happen when you are not cognizant. People are used to things a certain way. Things play out in the media that make your mind think a certain way, and you don’t even realize it. You may not even want to be that way.

Continue to: Unconscious bias is a barrier to ensuring equity...

 

 

Unconscious bias is a barrier to ensuring equity

Dr. Levy: One very important point you just made is that we as the system need to be able to recognize those unconscious things, the language that we use, the disparaging remarks, the things that put people down, as well as the things that keep people out of promotion.

There are some interesting data about both race and gender and the language that we use when we write recommendations for people, that we do things unconsciously. The big message to all of us at the end is to open our minds to where those things can occur. For myself, professionally, I keep a list of words that I use when I write recommendations. I measure myself to ensure that I am using the same language for men and women, for Black and White. I think we need to overcome the system and the structure to create real equity—not equality but equity.

It begins with being real about the issues

Dr. Johnson: It’s a bigger problem than the existence of bias and racism. I think these are systemic issues that have been cultivated over centuries that have never been addressed. The true issue is that we deny that these are problems and refuse to talk about it because it makes us uncomfortable. To truly make things more equitable, we have to push our levels of comfort to be able to talk about things in a healthy manner, be open and transparent, and to start to understand how we are thinking about certain things. When you can see it, you can start to implement changes and start to change mentalities and thought processes.

For me, people say, “You don’t look like a doctor.” I get that all the time—because I have tattoos and earrings. I wear my hair in a mohawk. The image of what success looks like has been manifested through our media and culture, and it has imprinted on our minds as to how things are supposed to be. If someone doesn’t fit those molds, we start to shun them out, or we start to exhibit biases against those things. What I am trying to do is change that thought process of what a successful or a professional person looks like. It doesn’t have a look. It is not a White or Black thing. It’s an intellect, a mindset, a way of living. You have to treat every person as an individual and take all the biases out of it and understand where they are coming from and what they have to offer to the profession.

Dr. Levy: I personally was so impressed by you when I met you. I was impressed by the tattoos and the earrings, and my initial response to them was exactly that biased, “Oh, who is this person?” I checked that at the door, listened to you, and was really impressed at your surgical skill, your knowledge, your background. I am really grateful that you have been willing to spend the time to share that with everyone.

Dr. Johnson: Thank you for this discussion.

To watch the full interview between Drs. Levy and Johnson, visit: https://www.mdedge.com/obgyn/article/228507/facing-systemic-racism-health-care-inequities-medical-education. ●

OBG Management takes the issues of systemic and structural racism incredibly seriously--not just by talking about it but by trying to highlight areas in medicine, particularly in obstetrics and gynecology, that are barriers to progress. In this new series for OBG Management, Board Member Barbara Levy, MD, faces the issues head-on, beginning with this peer-to-peer interview with Pierre Johnson, MD, ObGyn in Chicago, Illinois. Watch for future installments in upcoming issues of OBG Management.

Finding inspiration among life’s challenges

Barbara Levy, MD: I am fortunate to have met Pierre serendipitously at a training that we were both attending and was impressed by Dr. Johnson’s life story, his passion and commitment, and his dedication—not only to his personal career but also to raising up other young men of color by trying to break down barriers that face them. His life story highlights those areas of systemic and structural problems that all of us together need to address if we are going to make any progress.

Pierre Johnson, MD: Thank you, Barbara. A little about myself: I am a board-certified ObGyn, and I specialize in minimally invasive surgery. I was born on the South side of Chicago, experiencing gang violence, drugs, and substandard, underserved schools. Long story short, I had a very rough upbringing. I had a single mom and several different issues at home. I am the oldest of 5 siblings, and life was tough.

But I knew that I wanted to do something different with my life. I saw that there was a need in my community as far as health care was concerned, in particular women’s health and childbirth. I knew early on that I wanted to be an ObGyn, and the reason had a lot to do with The Cosby Show. It was the only example of a positive, successful Black man that I saw. No one graduated from college in my family. There weren’t any models of young Black excellence around me. Saying that I wanted to be a doctor planted a seed. I was 9 when my mom became pregnant with my first sibling, and it was fascinating to me. The physiology of pregnancy, and eventually childbirth, was extremely fascinating to me; it set me off on my journey to be an ObGyn.

As I got older, things didn’t get any easier. I went to high school in one of the toughest areas on the South side of Chicago. Gang violence, and violence in and of itself, were all around me, but I was able to stay focused. I went on to Xavier University in Louisiana.

Dr. Levy: There are some important things that I learned from your book and from talking to you at our first meeting. Your mom’s ObGyn, when she was pregnant with your next youngest sibling, was also a Black ObGyn. He took some time to take you under wing?

Dr. Johnson: He did. My mom’s ObGyn was a Black man. Other than The Cosby Show, that’s the only time I saw something like that. When I spoke to him, he really took the time to answer my questions and show me that he was like me; he wasn’t just a far-off mythical person, or something that I could not obtain.

Continue to: Seeing is believing when it comes to success...

Seeing is believing when it comes to success

Dr. Levy: Do you think it was important to have a role model who wasn’t a sports star?

Dr. Johnson: If you can’t see it, you can’t achieve it. He took his time to really talk to me, and it’s the little things for kids that go a long way in their life experience. I still have a relationship with him to this day. How he handled me as a kid made me realize that this is something that I could do. That was extremely important for me.

Dr. Levy: One of the structural things I think we need to point out is that the ability to see yourself as someone successful is critical. When we see 1,000 images a day and they are all White, and they are all so different from where we are that it gets incorporated into our sense of being. I think that’s really difficult for those of us of with privilege to understand what that privilege is.

Dr. Johnson: Absolutely, and I’ll even go further. In residency, 2 White females were my classmates, and both of their parents were doctors. They had grandparents who were doctors. My mom was addicted to drugs; my father was not around. They had been talking medicine since they were 5. You have to make things equitable, but in medicine it’s really not equitable. In medicine, what we don’t realize is that there is an importance for all aspects of someone’s upbringing and environment, and it’s not just what they can regurgitate on a standardized test. If a patient can’t relate to you and tell you what is wrong with them, how can you adequately treat them?

Dr. Levy: Even if they are trying to tell me, but I can’t hear it because I don’t have the language and I don’t have the background. There are really good data to show, in fact, that Black male physicians do a better job at engaging Black men to manage their hypertension.¹ When we look at the inequities in birth outcomes for women of color, indigenous women and Black women, there’s evidence that providers who come from a similar background do a better job.

Dr. Johnson: There was the study of Black infants that just came out about them dying at a 3-time higher rate in non-Black physicians’ hands.² These things need to be recognized. They need to be discussed, and they need to be identified as issues and then, realistically, we need to start talking about solutions, not get offended by what actual statistics are saying.

Foundational inequities in education

Dr. Levy: To address some of the barriers that you faced: I know that you went to a high school that was not geared toward pushing students into professional careers. Your colleagues, however, had educations that prepared them for the standardized tests and other things that they would face academically.

Dr. Johnson: People think I am kidding when I say it, but when I went into college, I didn’t know what a periodic table was. I saw it, but I had no idea what these things meant. I didn’t have any sciences or any AP classes in high school. I did well, but grades are smoke and mirrors. The true test of medicine comes with testing. From the MCATs to the boards, every step of the way there is a standardized test.

Knowledge is something that you can obtain, but test taking is a cultivated skill that happens from a very early age. Trying to teach an adult or someone in their late teens a skill that they should have learned as a kid is difficult. For me, I did not have that, so I had to program myself. I had to learn how to fundamentally take tests as an adult, where most people understand how to do that going into college and professional school.

Dr. Levy: I was impressed with your resilience. I think all of us as human beings, if we fail a test, we take it personally and think it’s about our lack of knowledge. One of the insights that you came to was that failure on those things was not that you didn’t study hard enough. In fact, you probably studied 4 times harder than most other people. You had the knowledge. Being able to get that knowledge into a standardized structured test score was the huge challenge for you.

Dr. Johnson: That’s it. I can remember taking the MCAT, and if you looked at the step 1 book, I could regurgitate to you everything on that page. However, it’s not a test about do you know it or not. It’s an understanding of the English language and how to break things down to make things fit into particular scenarios.

Continue to: A college experience focused on growth and exposure...

 

 

A college experience focused on growth and exposure

Dr. Levy: I was impressed by the distinction between your experience at Xavier University where there was a lot of support and guidance and help in your premed program, and what happened to you when you hit medical school.

Dr. Johnson: Xavier University in Louisiana is the number 1 institution in the country for getting minorities into professional school. They understand that they have kids that are brilliant but underprepared, and just have not had the background to actually tackle some of these tough curriculums. I always had good grades in school. But by not being challenged, I didn’t know what I didn’t really know. So now that I was seeing biology, chemistry for the first time, and trying to tackle it; there’s a failure point. I didn’t know how to take tests, and I didn’t know how to study properly. The harder I tried, the worse things got for me.

Xavier has seen that story a multitude of times. If I went to a bigger or predominantly White university, a counselor would have told me, “Well, medicine’s maybe not for you. You can’t handle a premed curriculum.” Instead, I said, “Listen, I’m studying. I’m doing all of these things, and I’m not hacking it.” And they broke it down: “Let’s get you into study groups with kids that have had these type of AP classes before. We’ll have you watch how they study,” and everything started to click. That facilitation of how to adjust to this curriculum was a godsend. It’s the only reason I’m here. I am a prime example of being brilliant enough to be able to do it, but needing the infrastructure and a system set up.

Dr. Levy: There’s a great book by Carol Dweck called Mindset that talks about education of young kids and putting them into silos so early in life; the brilliant kids go into the AP courses and the rest are labeled as inadequate. It’s assumed in a fixed mindset based on their heredity and IQ, and not based on the fact that they have not been exposed to the right things.

Xavier was growing you into the man who could, in fact, do all of those things. I think that is one of the systemic and structural issues that we have—that fixed mindset that frames a kid who is not succeeding as therefore unable to succeed, as opposed to framing that child as not having the correct tools.

New tribulations of medical school

Dr. Johnson: Absolutely. I think what Xavier did for me is to at least let me understand what I needed to do, how to comprehend and retain information, which I never had been exposed to before. Those years were very important to establishing a foundation. When going to medical school, it was like, “There’s no more excuses. What could be the problem now?” Well, now let’s talk about taking tests—a whole different skill. Xavier focused on getting me to understand how to structure my thought process and knowledge base. In medical school I had to apply those skills (because if you can’t apply them, there’s no fit).

My second through fourth year of medical school, I was the only African-American kid in my class. I was spending 20-hour days sometimes just studying, trying to overcompensate by knowing as much as I possibly could and thinking that would propel me from the test-taking standpoint. Even though I didn’t have a lot of classmates in medical school that looked like me, I did have mentors that looked similarly, who really saw potential in me. Dr. Frederick Horvath, a nephrologist in Peoria said, “What are you doing? I want you to get out of these books, and let’s go out to lunch.”

He ended up buying me some instrumental books, really talked to me, listening to my background and understanding how driven I was as a person. He took me under his wing for the rest of medical school and said, “This is how you navigate through these spaces. Yes, you need to have a fund of knowledge to be able to take these tests, but you need to start understanding how to apply it to these questions.” I’m forever grateful to Dr. Horvath for doing that because it was a point in time where I was lost and struggling.

Continue to: Hitting a stride but facing racism head-on...

 

 

Hitting a stride but facing racism head-on

Dr. Levy: You talk about the systemic and pervasive racism that was on the wards when you hit them in fourth year. If you don’t mind sharing just a little bit of that, it would help people reading this to have a better understanding of the kinds of barriers that are out there.

Dr. Johnson: Even when I talk about it today, it bothers me.

I went to medical school in Peoria, Illinois, not far from the home of the Ku Klux Klan. At that time, once you got out of Chicago it was a very brutal place, with systemic racism throughout. I was a young Black kid going through a process that not many young Black kids from the South side of Chicago go through, and you had people who had never seen anyone like me. When I was going through my clinical rotations, I knew what I was up against. I was dressed “to the T” every day, arriving early, leaving late, trying to answer questions. I would look at the evaluations, and they would be disparaging. I would look at my counterparts, how their evaluations were, and how people would respond to them, and it would be completely different.

Surgery was the part of ObGyn that I really grew to love more than anything, even more than obstetrics. When general surgery came, I wanted to take it very seriously and learn as much as I possibly could. From the beginning, I knew there was a problem because the chief resident, an older White man, wouldn’t look me in the eye or talk to me. He would make disparaging remarks. The thing that stuck out in my mind the most was when I was in the operating room transporting patients, just like a medical student did, and he came up behind me and said, “You know, Pierre, this is where a small mind and a strong back come into play.” For me, it took me to a place where I had to corral my emotions and thoughts because I just wanted to lash out and just tell him how racist and horrible that was for him to say that to me. I explained this to the powers that be, the director of the department, and they basically blew it off to the side.

When it came down to the end of the evaluation period, I passed with flying colors. But they gave me an incomplete because of that chief resident and his remarks on my evaluations. He had 3 pages of report about me as a person and as a student. He said that he had difficulty in expressing his opinions about me because of possible cultural biases that he may have had. He put “cultural biases” in an evaluation, and they looked at that and said that was enough for me to have to remediate my time. I was required to do an extra month in Pontiac, Illinois, which is even more rural than Peoria, because of a racist person that did not give me a fair opportunity because I was Black.

Like everything else in life, it was a learning experience. It’s why I fight so hard today. It’s why I’m so passionate about equity, not only in medicine but also in all aspects of society. It shows why we have police brutality and Black men dying in the streets. It shows how this happens because there are cultural and implicit biases that play out in every part of life, and we are not honest about it. Until we are honest about it and until we say that this is happening and there is something that needs to be done to address it, it’s going to continue to happen. That is my fight.

Exposing the unspoken power struggle

Dr. Levy: I couldn’t agree more. Attributing things like that to the individual, where you talk about a White man in power and a power structure that didn’t literally physically beat you but did beat you into submission. You talk about how to succeed in medical school, and how you had to suck it up and submit to something that was incredibly unfair. You understood, you were old enough, mature enough, to understand that if you fought back, you were going to lose. The only opportunity you had was to submit to that inequity and push forward.

Dr. Johnson: When I did try to fight, the chair of the department told me that either I accept the consequences or I would not graduate from medical school and be forced to do another year. That struck a chord with me. I think that happens a lot in our society, and it needs to be exposed.

Past experiences reflected in today’s society

Dr. Levy: Can you talk about what you faced in your ObGyn residency in terms of the systemic pushback, people not taking your orders, people questioning you. I know that I have heard that a great deal, and I experienced that myself as a woman.

Dr. Johnson: We look at the things that are happening now, everything from George Floyd’s murder to Colin Kaepernick taking a knee. These things are 10 years past when I first started residency. The year before I started residency, there was a noose hanging on the capitol lawn of Springfield, Illinois’ capital city. There’s systemic racism and hatred there. When I first started on the wards of my first year of ObGyn, again, I was the very first Black resident of my program’s history. Nobody could relate to me.

I went from a year-long general surgery internship at Washington Hospital Center in Washington, DC, to ObGyn residency. In the first 2 months, there were complaints of, “He’s not answering his pages. He’s not being prompt.” I went to my program director and said, “Listen, I have never had one complaint like this. There’s a problem here. And there’s a problem when I’m on the floor: When trying to give orders to nurses, they’re not taking them. I had to tell a couple of nurses, ‘I’m Dr. Johnson. Don’t call me by my first name, especially not in front of patients.’”

My director was just not hearing me, because the entire scenario was something they had never been exposed to. Systemic racism is real, and unless you experience it, it’s very difficult to accept that it is happening. But biases happen when you are not cognizant. People are used to things a certain way. Things play out in the media that make your mind think a certain way, and you don’t even realize it. You may not even want to be that way.

Continue to: Unconscious bias is a barrier to ensuring equity...

 

 

Unconscious bias is a barrier to ensuring equity

Dr. Levy: One very important point you just made is that we as the system need to be able to recognize those unconscious things, the language that we use, the disparaging remarks, the things that put people down, as well as the things that keep people out of promotion.

There are some interesting data about both race and gender and the language that we use when we write recommendations for people, that we do things unconsciously. The big message to all of us at the end is to open our minds to where those things can occur. For myself, professionally, I keep a list of words that I use when I write recommendations. I measure myself to ensure that I am using the same language for men and women, for Black and White. I think we need to overcome the system and the structure to create real equity—not equality but equity.

It begins with being real about the issues

Dr. Johnson: It’s a bigger problem than the existence of bias and racism. I think these are systemic issues that have been cultivated over centuries that have never been addressed. The true issue is that we deny that these are problems and refuse to talk about it because it makes us uncomfortable. To truly make things more equitable, we have to push our levels of comfort to be able to talk about things in a healthy manner, be open and transparent, and to start to understand how we are thinking about certain things. When you can see it, you can start to implement changes and start to change mentalities and thought processes.

For me, people say, “You don’t look like a doctor.” I get that all the time—because I have tattoos and earrings. I wear my hair in a mohawk. The image of what success looks like has been manifested through our media and culture, and it has imprinted on our minds as to how things are supposed to be. If someone doesn’t fit those molds, we start to shun them out, or we start to exhibit biases against those things. What I am trying to do is change that thought process of what a successful or a professional person looks like. It doesn’t have a look. It is not a White or Black thing. It’s an intellect, a mindset, a way of living. You have to treat every person as an individual and take all the biases out of it and understand where they are coming from and what they have to offer to the profession.

Dr. Levy: I personally was so impressed by you when I met you. I was impressed by the tattoos and the earrings, and my initial response to them was exactly that biased, “Oh, who is this person?” I checked that at the door, listened to you, and was really impressed at your surgical skill, your knowledge, your background. I am really grateful that you have been willing to spend the time to share that with everyone.

Dr. Johnson: Thank you for this discussion.

To watch the full interview between Drs. Levy and Johnson, visit: https://www.mdedge.com/obgyn/article/228507/facing-systemic-racism-health-care-inequities-medical-education. ●

Medicare officials stuck with their plan to increase payments for office visits for primary care and several other specialties that focus on helping patients manage complex conditions such as diabetes. In doing so, Medicare also finalized cuts for other fields, triggering a new wave of protests.

The final version of the 2021 Medicare physician fee schedule was unveiled on the night of Dec. 1. The Centers for Medicare & Medicaid Services posted an unofficial copy of the rule, which will later be published in the Federal Register.

CMS said it completed work on this massive annual review of payments for clinicians later than it usually does because of the demands of the federal response to the COVID-19 pandemic. The 2021 physician fee rule will take effect within a 30-day period instead of the usual 60-day time frame.

The rule, which runs to more than 2,100 pages, makes myriad changes in Medicare policies, including rules on telehealth, and expands the roles of nurse practitioners and physician assistants.

The most contentious item proposed for 2021 was a reshuffling of payments among specialties as part of an overhaul of Medicare’s approach to valuing evaluation and management (E/M) services. There was broader support for other aspects of the E/M overhaul, which are intended to cut some of the administrative hassle clinicians face.

“This finalized policy marks the most significant updates to E/M codes in 30 years, reducing burden on doctors imposed by the coding system and rewarding time spent evaluating and managing their patients’ care,” CMS Administrator Seema Verma said in a statement. “In the past, the system has rewarded interventions and procedures over time spent with patients – time taken preventing disease and managing chronic illnesses.”

In the final rule, CMS summarized these results of the E/M changes in Table 106. CMS largely stuck with the approach outlined in a draft rule released in August, with minor changes in the amounts of cuts and increases.

Specialties in line for increases under the 2021 final physician fee schedule include allergy/immunology (9%), endocrinology (16%), family practice (13%), general practice (7%), geriatrics (3%), hematology/oncology (14%), internal medicine (4%), nephrology (6%), physician assistants (8%), psychiatry (7%), rheumatology (15%), and urology (8%).

In line for cuts would be anesthesiology (–8%), cardiac surgery (–8%), emergency medicine (–6%), general surgery (–6%), infectious disease (–4%), neurosurgery (–6%), physical/occupational therapy (–9%), plastic surgery (–7%), radiology (–10%), and thoracic surgery (–8%).

CMS had initially set these changes in 2021 pay in motion in the 2020 physician fee schedule. The agency subsequently faced significant opposition to its plans. Many physician groups sought to waive a “budget-neutral” approach to the E/M overhaul, which makes the offsetting of cuts necessary. They argued this would allow increased compensation for clinicians whose practices focus on office visits without requiring offsetting cuts from other fields of medicine.

The American Medical Association is among those urging Congress to prevent or postpone the payment reductions resulting from Medicare’s budget neutrality requirement as applied to the E/M overhaul.

In a Tuesday statement, AMA President Susan R. Bailey, MD, noted that many physicians are facing “substantial economic hardships due to COVID-19.”

By AMA’s calculations, CMS’ planned 2021 E/M overhaul could result in “a shocking reduction of 10.2% to Medicare payment rates,” according to Bailey’s statement. The AMA strongly supports other aspects of the E/M changes CMS finalized, which Bailey said will result in “simpler and more flexible” coding and documentation.

The Surgical Care Coalition, which represents about a dozen medical specialty associations, is asking members of Congress to block the full implementation of the E/M overhaul.

In a Dec. 1 statement, the coalition urged the passage of a bill (HR 8702) that has been introduced in the House by a bipartisan duo of physicians, Rep. Ami Bera, MD (D-Calif.), and Rep. Larry Bucshon, MD (R-Ind.). Their bill would effectively block the cuts from going into effect on January 1, 2021. It would provide an additional Medicare payment for certain services in 2021 and 2022 if the otherwise applicable payment is less than it would have been in 2020.

The Medicare E/M overhaul “was a dangerous policy even before the pandemic, and enacting it during the worst health care crisis in a century is unconscionable. If Congress fails to act, it will further strain a health care system that’s already been pushed to the brink due to the COVID-19 pandemic and undermine patient care,” said John A. Wilson, MD, president of the American Association of Neurological Surgeons, in a statement.

Also backing the Bera-Bucshon bill is the American College of Emergency Physicians. In a statement on Tuesday, ACEP President Mark Rosenberg, DO, MBA, urged Congress to act on this measure.

“Emergency physicians and other health care providers battling on the front lines of the ongoing pandemic are already under unprecedented financial strain as they continue to bear the brunt of COVID-19,” Dr. Rosenberg said. “These cuts would have a devastating impact for the future of emergency medicine and could seriously impede patients’ access to emergency care when they need it most.”
 

“Long overdue”

But there also are champions for the approach CMS took in the E/M overhaul. The influential Medicare Payment Advisory Commission (MedPAC) has argued strongly for keeping the budget-neutral approach to the E/M overhaul.

In an Oct. 2 comment to CMS about the draft 2021 physician fee schedule, MedPAC Chairman Michael E. Chernew, PhD, said this approach would “help rebalance the fee schedule from services that have become overvalued to services that have become undervalued.”

This budget-neutral approach also “will go further in reducing the large gap in compensation between primary care physicians (who had a median income of $243,000 in 2018) and specialists such as surgeons (whose median income was $426,000 in 2018),” Dr. Chernew wrote.

In a Tuesday tweet, Robert B. Doherty, senior vice president of governmental affairs and public policy for the American College of Physicians, said CMS had “finalized long overdue payment increases for primary and comprehensive care including an add-in for more complex visits.”

The American Academy of Family Physicians joined ACP in a November 30 letter to congressional leaders, urging them to allow Medicare “to increase investment in primary care, benefiting millions of Medicare patients and the program itself, and reject last minute efforts to prevent these essential and long-overdue changes from going fully into effect on January 1, 2021.”

In the letter, AAFP and ACP and their cosigners argued for a need to address “underinvestment” in primary care by finalizing the E/M overhaul.

“Given that six in ten American adults have a chronic disease and four in ten have two or more chronic conditions, why would we, as a country, accept such an inadequate investment in the very care model that stands to provide maximum value to these patients?” they wrote. “Since we know that individuals with a longitudinal relationship with a primary care physician have better health outcomes and use fewer health care resources, why would we continue to direct money to higher-cost, marginal value services?”

A version of this article originally appeared on Medscape.com.

Medicare officials stuck with their plan to increase payments for office visits for primary care and several other specialties that focus on helping patients manage complex conditions such as diabetes. In doing so, Medicare also finalized cuts for other fields, triggering a new wave of protests.

The final version of the 2021 Medicare physician fee schedule was unveiled on the night of Dec. 1. The Centers for Medicare & Medicaid Services posted an unofficial copy of the rule, which will later be published in the Federal Register.

CMS said it completed work on this massive annual review of payments for clinicians later than it usually does because of the demands of the federal response to the COVID-19 pandemic. The 2021 physician fee rule will take effect within a 30-day period instead of the usual 60-day time frame.

The rule, which runs to more than 2,100 pages, makes myriad changes in Medicare policies, including rules on telehealth, and expands the roles of nurse practitioners and physician assistants.

The most contentious item proposed for 2021 was a reshuffling of payments among specialties as part of an overhaul of Medicare’s approach to valuing evaluation and management (E/M) services. There was broader support for other aspects of the E/M overhaul, which are intended to cut some of the administrative hassle clinicians face.

“This finalized policy marks the most significant updates to E/M codes in 30 years, reducing burden on doctors imposed by the coding system and rewarding time spent evaluating and managing their patients’ care,” CMS Administrator Seema Verma said in a statement. “In the past, the system has rewarded interventions and procedures over time spent with patients – time taken preventing disease and managing chronic illnesses.”

In the final rule, CMS summarized these results of the E/M changes in Table 106. CMS largely stuck with the approach outlined in a draft rule released in August, with minor changes in the amounts of cuts and increases.

Specialties in line for increases under the 2021 final physician fee schedule include allergy/immunology (9%), endocrinology (16%), family practice (13%), general practice (7%), geriatrics (3%), hematology/oncology (14%), internal medicine (4%), nephrology (6%), physician assistants (8%), psychiatry (7%), rheumatology (15%), and urology (8%).

In line for cuts would be anesthesiology (–8%), cardiac surgery (–8%), emergency medicine (–6%), general surgery (–6%), infectious disease (–4%), neurosurgery (–6%), physical/occupational therapy (–9%), plastic surgery (–7%), radiology (–10%), and thoracic surgery (–8%).

CMS had initially set these changes in 2021 pay in motion in the 2020 physician fee schedule. The agency subsequently faced significant opposition to its plans. Many physician groups sought to waive a “budget-neutral” approach to the E/M overhaul, which makes the offsetting of cuts necessary. They argued this would allow increased compensation for clinicians whose practices focus on office visits without requiring offsetting cuts from other fields of medicine.

The American Medical Association is among those urging Congress to prevent or postpone the payment reductions resulting from Medicare’s budget neutrality requirement as applied to the E/M overhaul.

In a Tuesday statement, AMA President Susan R. Bailey, MD, noted that many physicians are facing “substantial economic hardships due to COVID-19.”

By AMA’s calculations, CMS’ planned 2021 E/M overhaul could result in “a shocking reduction of 10.2% to Medicare payment rates,” according to Bailey’s statement. The AMA strongly supports other aspects of the E/M changes CMS finalized, which Bailey said will result in “simpler and more flexible” coding and documentation.

The Surgical Care Coalition, which represents about a dozen medical specialty associations, is asking members of Congress to block the full implementation of the E/M overhaul.

In a Dec. 1 statement, the coalition urged the passage of a bill (HR 8702) that has been introduced in the House by a bipartisan duo of physicians, Rep. Ami Bera, MD (D-Calif.), and Rep. Larry Bucshon, MD (R-Ind.). Their bill would effectively block the cuts from going into effect on January 1, 2021. It would provide an additional Medicare payment for certain services in 2021 and 2022 if the otherwise applicable payment is less than it would have been in 2020.

The Medicare E/M overhaul “was a dangerous policy even before the pandemic, and enacting it during the worst health care crisis in a century is unconscionable. If Congress fails to act, it will further strain a health care system that’s already been pushed to the brink due to the COVID-19 pandemic and undermine patient care,” said John A. Wilson, MD, president of the American Association of Neurological Surgeons, in a statement.

Also backing the Bera-Bucshon bill is the American College of Emergency Physicians. In a statement on Tuesday, ACEP President Mark Rosenberg, DO, MBA, urged Congress to act on this measure.

“Emergency physicians and other health care providers battling on the front lines of the ongoing pandemic are already under unprecedented financial strain as they continue to bear the brunt of COVID-19,” Dr. Rosenberg said. “These cuts would have a devastating impact for the future of emergency medicine and could seriously impede patients’ access to emergency care when they need it most.”
 

“Long overdue”

But there also are champions for the approach CMS took in the E/M overhaul. The influential Medicare Payment Advisory Commission (MedPAC) has argued strongly for keeping the budget-neutral approach to the E/M overhaul.

In an Oct. 2 comment to CMS about the draft 2021 physician fee schedule, MedPAC Chairman Michael E. Chernew, PhD, said this approach would “help rebalance the fee schedule from services that have become overvalued to services that have become undervalued.”

This budget-neutral approach also “will go further in reducing the large gap in compensation between primary care physicians (who had a median income of $243,000 in 2018) and specialists such as surgeons (whose median income was $426,000 in 2018),” Dr. Chernew wrote.

In a Tuesday tweet, Robert B. Doherty, senior vice president of governmental affairs and public policy for the American College of Physicians, said CMS had “finalized long overdue payment increases for primary and comprehensive care including an add-in for more complex visits.”

The American Academy of Family Physicians joined ACP in a November 30 letter to congressional leaders, urging them to allow Medicare “to increase investment in primary care, benefiting millions of Medicare patients and the program itself, and reject last minute efforts to prevent these essential and long-overdue changes from going fully into effect on January 1, 2021.”

In the letter, AAFP and ACP and their cosigners argued for a need to address “underinvestment” in primary care by finalizing the E/M overhaul.

“Given that six in ten American adults have a chronic disease and four in ten have two or more chronic conditions, why would we, as a country, accept such an inadequate investment in the very care model that stands to provide maximum value to these patients?” they wrote. “Since we know that individuals with a longitudinal relationship with a primary care physician have better health outcomes and use fewer health care resources, why would we continue to direct money to higher-cost, marginal value services?”

A version of this article originally appeared on Medscape.com.

Medicare officials stuck with their plan to increase payments for office visits for primary care and several other specialties that focus on helping patients manage complex conditions such as diabetes. In doing so, Medicare also finalized cuts for other fields, triggering a new wave of protests.

The final version of the 2021 Medicare physician fee schedule was unveiled on the night of Dec. 1. The Centers for Medicare & Medicaid Services posted an unofficial copy of the rule, which will later be published in the Federal Register.

CMS said it completed work on this massive annual review of payments for clinicians later than it usually does because of the demands of the federal response to the COVID-19 pandemic. The 2021 physician fee rule will take effect within a 30-day period instead of the usual 60-day time frame.

The rule, which runs to more than 2,100 pages, makes myriad changes in Medicare policies, including rules on telehealth, and expands the roles of nurse practitioners and physician assistants.

The most contentious item proposed for 2021 was a reshuffling of payments among specialties as part of an overhaul of Medicare’s approach to valuing evaluation and management (E/M) services. There was broader support for other aspects of the E/M overhaul, which are intended to cut some of the administrative hassle clinicians face.

“This finalized policy marks the most significant updates to E/M codes in 30 years, reducing burden on doctors imposed by the coding system and rewarding time spent evaluating and managing their patients’ care,” CMS Administrator Seema Verma said in a statement. “In the past, the system has rewarded interventions and procedures over time spent with patients – time taken preventing disease and managing chronic illnesses.”

In the final rule, CMS summarized these results of the E/M changes in Table 106. CMS largely stuck with the approach outlined in a draft rule released in August, with minor changes in the amounts of cuts and increases.

Specialties in line for increases under the 2021 final physician fee schedule include allergy/immunology (9%), endocrinology (16%), family practice (13%), general practice (7%), geriatrics (3%), hematology/oncology (14%), internal medicine (4%), nephrology (6%), physician assistants (8%), psychiatry (7%), rheumatology (15%), and urology (8%).

In line for cuts would be anesthesiology (–8%), cardiac surgery (–8%), emergency medicine (–6%), general surgery (–6%), infectious disease (–4%), neurosurgery (–6%), physical/occupational therapy (–9%), plastic surgery (–7%), radiology (–10%), and thoracic surgery (–8%).

CMS had initially set these changes in 2021 pay in motion in the 2020 physician fee schedule. The agency subsequently faced significant opposition to its plans. Many physician groups sought to waive a “budget-neutral” approach to the E/M overhaul, which makes the offsetting of cuts necessary. They argued this would allow increased compensation for clinicians whose practices focus on office visits without requiring offsetting cuts from other fields of medicine.

The American Medical Association is among those urging Congress to prevent or postpone the payment reductions resulting from Medicare’s budget neutrality requirement as applied to the E/M overhaul.

In a Tuesday statement, AMA President Susan R. Bailey, MD, noted that many physicians are facing “substantial economic hardships due to COVID-19.”

By AMA’s calculations, CMS’ planned 2021 E/M overhaul could result in “a shocking reduction of 10.2% to Medicare payment rates,” according to Bailey’s statement. The AMA strongly supports other aspects of the E/M changes CMS finalized, which Bailey said will result in “simpler and more flexible” coding and documentation.

The Surgical Care Coalition, which represents about a dozen medical specialty associations, is asking members of Congress to block the full implementation of the E/M overhaul.

In a Dec. 1 statement, the coalition urged the passage of a bill (HR 8702) that has been introduced in the House by a bipartisan duo of physicians, Rep. Ami Bera, MD (D-Calif.), and Rep. Larry Bucshon, MD (R-Ind.). Their bill would effectively block the cuts from going into effect on January 1, 2021. It would provide an additional Medicare payment for certain services in 2021 and 2022 if the otherwise applicable payment is less than it would have been in 2020.

The Medicare E/M overhaul “was a dangerous policy even before the pandemic, and enacting it during the worst health care crisis in a century is unconscionable. If Congress fails to act, it will further strain a health care system that’s already been pushed to the brink due to the COVID-19 pandemic and undermine patient care,” said John A. Wilson, MD, president of the American Association of Neurological Surgeons, in a statement.

Also backing the Bera-Bucshon bill is the American College of Emergency Physicians. In a statement on Tuesday, ACEP President Mark Rosenberg, DO, MBA, urged Congress to act on this measure.

“Emergency physicians and other health care providers battling on the front lines of the ongoing pandemic are already under unprecedented financial strain as they continue to bear the brunt of COVID-19,” Dr. Rosenberg said. “These cuts would have a devastating impact for the future of emergency medicine and could seriously impede patients’ access to emergency care when they need it most.”
 

“Long overdue”

But there also are champions for the approach CMS took in the E/M overhaul. The influential Medicare Payment Advisory Commission (MedPAC) has argued strongly for keeping the budget-neutral approach to the E/M overhaul.

In an Oct. 2 comment to CMS about the draft 2021 physician fee schedule, MedPAC Chairman Michael E. Chernew, PhD, said this approach would “help rebalance the fee schedule from services that have become overvalued to services that have become undervalued.”

This budget-neutral approach also “will go further in reducing the large gap in compensation between primary care physicians (who had a median income of $243,000 in 2018) and specialists such as surgeons (whose median income was $426,000 in 2018),” Dr. Chernew wrote.

In a Tuesday tweet, Robert B. Doherty, senior vice president of governmental affairs and public policy for the American College of Physicians, said CMS had “finalized long overdue payment increases for primary and comprehensive care including an add-in for more complex visits.”

The American Academy of Family Physicians joined ACP in a November 30 letter to congressional leaders, urging them to allow Medicare “to increase investment in primary care, benefiting millions of Medicare patients and the program itself, and reject last minute efforts to prevent these essential and long-overdue changes from going fully into effect on January 1, 2021.”

In the letter, AAFP and ACP and their cosigners argued for a need to address “underinvestment” in primary care by finalizing the E/M overhaul.

“Given that six in ten American adults have a chronic disease and four in ten have two or more chronic conditions, why would we, as a country, accept such an inadequate investment in the very care model that stands to provide maximum value to these patients?” they wrote. “Since we know that individuals with a longitudinal relationship with a primary care physician have better health outcomes and use fewer health care resources, why would we continue to direct money to higher-cost, marginal value services?”

A version of this article originally appeared on Medscape.com.

From the University of Toronto (Dr. Basuita, Corey L. Kamen, and Dr. Soong) and Sinai Health System (Corey L. Kamen, Cheryl Ethier, and Dr. Soong), Toronto, Ontario, Canada. Co-first authors are Manpreet Basuita, MD, and Corey L. Kamen, BSc.

Abstract

• Objective: Routine laboratory testing is common among medical inpatients; however, when ordered inappropriately testing can represent low-value care. We examined the impact of an evidence-based intervention bundle on utilization.
• Participants/setting: This prospective cohort study took place at a tertiary academic medical center and included 6424 patients admitted to the general internal medicine service between April 2016 and March 2018.
• Intervention: An intervention bundle, whose first components were implemented in July 2016, included computer order entry restrictions on repetitive laboratory testing, education, and audit-feedback.
• Measures: Data were extracted from the hospital electronic health record. The primary outcome was the number of routine blood tests (complete blood count, creatinine, and electrolytes) ordered per inpatient day.
• Analysis: Descriptive statistics were calculated for demographic variables. We used statistical process control charts to compare the baseline period (April 2016-June 2017) and the intervention period (July 2017-March 2018) for the primary outcome.
• Results: The mean number of combined routine laboratory tests ordered per inpatient day decreased from 1.19 (SD, 0.21) tests to 1.11 (SD, 0.05), a relative reduction of 6.7% (P < 0.0001). Mean cost per case related to laboratory tests decreased from $17.24 in the pre-intervention period to $16.17 in the post-intervention period (relative reduction of 6.2%). This resulted in savings of $26,851 in the intervention year.
• Conclusion: A laboratory intervention bundle was associated with small reductions in testing and costs. A routine test performed less than once per inpatient day may not be clinically appropriate or possible.

Keywords: utilization; clinical costs; quality improvement; QI intervention; internal medicine; inpatient.

Routine laboratory blood testing is a commonly used diagnostic tool that physicians rely on to provide patient care. Although routine blood testing represents less than 5% of most hospital budgets, routine use and over-reliance on testing among physicians makes it a target of cost-reduction efforts.^1-3 A variety of interventions have been proposed to reduce inappropriate laboratory tests, with varying results.^1,4-6 Successful interventions include providing physicians with fee data associated with ordered laboratory tests, unbundling panels of tests, and multicomponent interventions.⁶ We conducted a multifaceted quality improvement study to promote and develop interventions to adopt appropriate blood test ordering practices.

Methods

Setting

This prospective cohort study took place at Mount Sinai Hospital, a 443-bed academic hospital affiliated with the University of Toronto, where more than 2400 learners rotate through annually. The study was approved by the Mount Sinai Hospital Research Ethics Board.

Participants

We included all inpatient admissions to the general internal medicine service between April 2016 and March 2018. Exclusion criteria included a length of stay (LOS) longer than 365 days and admission to a critical care unit. Patients with more than 1 admission were counted as separate hospital inpatient visits.

Intervention

Based on internal data, we targeted the top 3 most frequently ordered routine blood tests: complete blood count (CBC), creatinine, and electrolytes. Trainee interviews revealed that habit, bundled order sets, and fear of “missing something” contributed to inappropriate routine blood test ordering. Based on these root causes, we used the Model for Improvement to iteratively develop a multimodal intervention that began in July 2016.^7,8 This included a change to the computerized provider order entry (CPOE) to nudge clinicians to a restrictive ordering strategy by substituting the “Daily x3” frequency of blood test ordering with a “Daily x1” option on a pick list of order options. Clinicians could still order daily routine blood tests for any specified duration, but would have to do so by manually changing the default setting within the CPOE.

From July 2017 to March 2018, the research team educated residents on appropriate laboratory test ordering and provided audit and feedback data to the clinicians. Diagnostic uncertainty was addressed in teaching sessions. Attending physicians were surveyed on appropriate indications for daily laboratory testing for each of CBC, electrolytes, and creatinine. Appropriate indications (Figure 1) were displayed in visible clinical areas and incorporated into teaching sessions.⁹

Clinician teams received real-time performance data on their routine blood test ordering patterns compared with an institutional benchmark. Bar graphs of blood work ordering rates (sum of CBCs, creatinine, and electrolytes ordered for all patients on a given team divided by the total LOS for all patients) were distributed to each internal medicine team via email every 2 weeks (Figure 2).^1,10-12

Data Collection and Analysis

Data were extracted from the hospital electronic health record (EHR). The primary outcome was the number of routine blood tests (CBC, creatinine, and electrolytes) ordered per inpatient day. Descriptive statistics were calculated for demographic variables. We used statistical process control (SPC) charts to compare the baseline period (April 2016-June 2017) and the intervention period (July 2017-March 2018) for the primary outcome. SPC charts display process changes over time. Data are plotted in chronological order, with the central line representing the outcome mean, an upper line representing the upper control limit, and a lower line representing the lower control limit. The upper and lower limits were set at 3δ, which correspond to 3 standard deviations above and below the mean. Six successive points above or beyond the mean suggests “special cause variation,” indicating that observed results are unlikely due to secular trends. SPC charts are commonly used quality tools for process improvement as well as research.^13-16 These charts were created using QI Macros SPC software for Excel V. 2012.07 (KnowWare International, Denver, CO).

The direct cost of each laboratory test was acquired from the hospital laboratory department. The cost of each laboratory test (CBC = $7.54/test, electrolytes = $2.04/test, creatinine = $1.28/test, in Canadian dollars) was subsequently added together and multiplied by the pre- and post-intervention difference of total blood tests saved per inpatient day and then multiplied by 365 to arrive at an estimated cost savings per year.

Results

Over the study period, there were 6424 unique patient admissions on the general internal medicine service, with a median LOS of 3.5 days (Table).

The majority of inpatient visits had at least 1 test of CBC (80%; mean, 3.6 tests/visit), creatinine (79.3%; mean, 3.5 tests/visit), or electrolytes (81.6%; mean, 3.9 tests/visit) completed. In total, 56,767 laboratory tests were ordered.

Following the intervention, there was a reduction in both rates of routine blood test orders and their associated costs, with a shift below the mean. The mean number of tests ordered (combined CBC, creatinine, and electrolytes) per inpatient day decreased from 1.19 (SD, 0.21) in the pre-intervention period to 1.11 (SD, 0.05) in the post-intervention period (P < 0.0001), representing a 6.7% relative reduction (Figure 3). We observed a 6.2% relative reduction in costs per inpatient day, translating to a total savings of $26,851 over 1 year for the intervention period.

Discussion

Our study suggests that a multimodal intervention, including CPOE restrictions, resident education with posters, and audit and feedback strategies, can reduce lab test ordering on general internal medicine wards. This finding is similar to those of previous studies using a similar intervention, although different laboratory tests were targeted.^{1,2,5,6,10,17}

Our study found lower test result reductions than those reported by a previous study, which reported a relative reduction of 17% to 30%,¹⁸ and by another investigation that was conducted recently in a similar setting.¹⁷ In the latter study, reductions in laboratory testing were mostly found in nonroutine tests, and no significant improvements were noted in CBC, electrolytes, and creatine, the 3 tests we studied over the same duration.¹⁷ This may represent a ceiling effect to reducing laboratory testing, and efforts to reduce CBC, electrolytes, and creatinine testing beyond 0.3 to 0.4 tests per inpatient day (or combined 1.16 tests per inpatient day) may not be clinically appropriate or possible. This information can guide institutions to include other areas of overuse based on rates of utilization in order to maximize the benefits from a resource intensive intervention.

There are a number of limitations that merit discussion. First, observational studies do not demonstrate causation; however, to our knowledge, there were no other co-interventions that were being conducted during the study duration. One important note is that our project’s intervention began in July, at which point there are new internal medicine residents beginning their training. As the concept of resource allocation becomes more important, medical schools are spending more time educating students about Choosing Wisely, and, therefore, newer cohorts of residents may be more cognizant of appropriate blood testing. Second, this is a single-center study, limiting generalizability; however, we note that many other centers have reported similar findings. Another limitation is that we do not know whether there were any adverse clinical events associated with blood work ordering that was too restrictive, although informal tracking of STAT laboratory testing remained stable throughout the study period. It is important to ensure that blood work is ordered in moderation and tailored to patients using one’s clinical judgment.

Future Directions

We observed modest reductions in the quantity and costs associated with a quality improvement intervention aimed at reducing routine blood testing. A baseline rate of laboratory testing of less than 1 test per inpatient day may require including other target tests to drive down absolute utilization.

Corresponding author: Christine Soong, MD, MSc, 433-600 University Avenue, Toronto, Ontario, Canada M5G 1X5; [email protected].

Financial disclosures: None.

From the University of Toronto (Dr. Basuita, Corey L. Kamen, and Dr. Soong) and Sinai Health System (Corey L. Kamen, Cheryl Ethier, and Dr. Soong), Toronto, Ontario, Canada. Co-first authors are Manpreet Basuita, MD, and Corey L. Kamen, BSc.

Abstract

• Objective: Routine laboratory testing is common among medical inpatients; however, when ordered inappropriately testing can represent low-value care. We examined the impact of an evidence-based intervention bundle on utilization.
• Participants/setting: This prospective cohort study took place at a tertiary academic medical center and included 6424 patients admitted to the general internal medicine service between April 2016 and March 2018.
• Intervention: An intervention bundle, whose first components were implemented in July 2016, included computer order entry restrictions on repetitive laboratory testing, education, and audit-feedback.
• Measures: Data were extracted from the hospital electronic health record. The primary outcome was the number of routine blood tests (complete blood count, creatinine, and electrolytes) ordered per inpatient day.
• Analysis: Descriptive statistics were calculated for demographic variables. We used statistical process control charts to compare the baseline period (April 2016-June 2017) and the intervention period (July 2017-March 2018) for the primary outcome.
• Results: The mean number of combined routine laboratory tests ordered per inpatient day decreased from 1.19 (SD, 0.21) tests to 1.11 (SD, 0.05), a relative reduction of 6.7% (P < 0.0001). Mean cost per case related to laboratory tests decreased from $17.24 in the pre-intervention period to $16.17 in the post-intervention period (relative reduction of 6.2%). This resulted in savings of $26,851 in the intervention year.
• Conclusion: A laboratory intervention bundle was associated with small reductions in testing and costs. A routine test performed less than once per inpatient day may not be clinically appropriate or possible.

Keywords: utilization; clinical costs; quality improvement; QI intervention; internal medicine; inpatient.

Routine laboratory blood testing is a commonly used diagnostic tool that physicians rely on to provide patient care. Although routine blood testing represents less than 5% of most hospital budgets, routine use and over-reliance on testing among physicians makes it a target of cost-reduction efforts.^1-3 A variety of interventions have been proposed to reduce inappropriate laboratory tests, with varying results.^1,4-6 Successful interventions include providing physicians with fee data associated with ordered laboratory tests, unbundling panels of tests, and multicomponent interventions.⁶ We conducted a multifaceted quality improvement study to promote and develop interventions to adopt appropriate blood test ordering practices.

Methods

Setting

This prospective cohort study took place at Mount Sinai Hospital, a 443-bed academic hospital affiliated with the University of Toronto, where more than 2400 learners rotate through annually. The study was approved by the Mount Sinai Hospital Research Ethics Board.

Participants

We included all inpatient admissions to the general internal medicine service between April 2016 and March 2018. Exclusion criteria included a length of stay (LOS) longer than 365 days and admission to a critical care unit. Patients with more than 1 admission were counted as separate hospital inpatient visits.

Intervention

Based on internal data, we targeted the top 3 most frequently ordered routine blood tests: complete blood count (CBC), creatinine, and electrolytes. Trainee interviews revealed that habit, bundled order sets, and fear of “missing something” contributed to inappropriate routine blood test ordering. Based on these root causes, we used the Model for Improvement to iteratively develop a multimodal intervention that began in July 2016.^7,8 This included a change to the computerized provider order entry (CPOE) to nudge clinicians to a restrictive ordering strategy by substituting the “Daily x3” frequency of blood test ordering with a “Daily x1” option on a pick list of order options. Clinicians could still order daily routine blood tests for any specified duration, but would have to do so by manually changing the default setting within the CPOE.

From July 2017 to March 2018, the research team educated residents on appropriate laboratory test ordering and provided audit and feedback data to the clinicians. Diagnostic uncertainty was addressed in teaching sessions. Attending physicians were surveyed on appropriate indications for daily laboratory testing for each of CBC, electrolytes, and creatinine. Appropriate indications (Figure 1) were displayed in visible clinical areas and incorporated into teaching sessions.⁹

Clinician teams received real-time performance data on their routine blood test ordering patterns compared with an institutional benchmark. Bar graphs of blood work ordering rates (sum of CBCs, creatinine, and electrolytes ordered for all patients on a given team divided by the total LOS for all patients) were distributed to each internal medicine team via email every 2 weeks (Figure 2).^1,10-12

Data Collection and Analysis

Data were extracted from the hospital electronic health record (EHR). The primary outcome was the number of routine blood tests (CBC, creatinine, and electrolytes) ordered per inpatient day. Descriptive statistics were calculated for demographic variables. We used statistical process control (SPC) charts to compare the baseline period (April 2016-June 2017) and the intervention period (July 2017-March 2018) for the primary outcome. SPC charts display process changes over time. Data are plotted in chronological order, with the central line representing the outcome mean, an upper line representing the upper control limit, and a lower line representing the lower control limit. The upper and lower limits were set at 3δ, which correspond to 3 standard deviations above and below the mean. Six successive points above or beyond the mean suggests “special cause variation,” indicating that observed results are unlikely due to secular trends. SPC charts are commonly used quality tools for process improvement as well as research.^13-16 These charts were created using QI Macros SPC software for Excel V. 2012.07 (KnowWare International, Denver, CO).

The direct cost of each laboratory test was acquired from the hospital laboratory department. The cost of each laboratory test (CBC = $7.54/test, electrolytes = $2.04/test, creatinine = $1.28/test, in Canadian dollars) was subsequently added together and multiplied by the pre- and post-intervention difference of total blood tests saved per inpatient day and then multiplied by 365 to arrive at an estimated cost savings per year.

Results

Over the study period, there were 6424 unique patient admissions on the general internal medicine service, with a median LOS of 3.5 days (Table).

The majority of inpatient visits had at least 1 test of CBC (80%; mean, 3.6 tests/visit), creatinine (79.3%; mean, 3.5 tests/visit), or electrolytes (81.6%; mean, 3.9 tests/visit) completed. In total, 56,767 laboratory tests were ordered.

Following the intervention, there was a reduction in both rates of routine blood test orders and their associated costs, with a shift below the mean. The mean number of tests ordered (combined CBC, creatinine, and electrolytes) per inpatient day decreased from 1.19 (SD, 0.21) in the pre-intervention period to 1.11 (SD, 0.05) in the post-intervention period (P < 0.0001), representing a 6.7% relative reduction (Figure 3). We observed a 6.2% relative reduction in costs per inpatient day, translating to a total savings of $26,851 over 1 year for the intervention period.

Discussion

Our study suggests that a multimodal intervention, including CPOE restrictions, resident education with posters, and audit and feedback strategies, can reduce lab test ordering on general internal medicine wards. This finding is similar to those of previous studies using a similar intervention, although different laboratory tests were targeted.^{1,2,5,6,10,17}

Our study found lower test result reductions than those reported by a previous study, which reported a relative reduction of 17% to 30%,¹⁸ and by another investigation that was conducted recently in a similar setting.¹⁷ In the latter study, reductions in laboratory testing were mostly found in nonroutine tests, and no significant improvements were noted in CBC, electrolytes, and creatine, the 3 tests we studied over the same duration.¹⁷ This may represent a ceiling effect to reducing laboratory testing, and efforts to reduce CBC, electrolytes, and creatinine testing beyond 0.3 to 0.4 tests per inpatient day (or combined 1.16 tests per inpatient day) may not be clinically appropriate or possible. This information can guide institutions to include other areas of overuse based on rates of utilization in order to maximize the benefits from a resource intensive intervention.

There are a number of limitations that merit discussion. First, observational studies do not demonstrate causation; however, to our knowledge, there were no other co-interventions that were being conducted during the study duration. One important note is that our project’s intervention began in July, at which point there are new internal medicine residents beginning their training. As the concept of resource allocation becomes more important, medical schools are spending more time educating students about Choosing Wisely, and, therefore, newer cohorts of residents may be more cognizant of appropriate blood testing. Second, this is a single-center study, limiting generalizability; however, we note that many other centers have reported similar findings. Another limitation is that we do not know whether there were any adverse clinical events associated with blood work ordering that was too restrictive, although informal tracking of STAT laboratory testing remained stable throughout the study period. It is important to ensure that blood work is ordered in moderation and tailored to patients using one’s clinical judgment.

Future Directions

We observed modest reductions in the quantity and costs associated with a quality improvement intervention aimed at reducing routine blood testing. A baseline rate of laboratory testing of less than 1 test per inpatient day may require including other target tests to drive down absolute utilization.

Corresponding author: Christine Soong, MD, MSc, 433-600 University Avenue, Toronto, Ontario, Canada M5G 1X5; [email protected].

Financial disclosures: None.

From the University of Toronto (Dr. Basuita, Corey L. Kamen, and Dr. Soong) and Sinai Health System (Corey L. Kamen, Cheryl Ethier, and Dr. Soong), Toronto, Ontario, Canada. Co-first authors are Manpreet Basuita, MD, and Corey L. Kamen, BSc.

Abstract

• Objective: Routine laboratory testing is common among medical inpatients; however, when ordered inappropriately testing can represent low-value care. We examined the impact of an evidence-based intervention bundle on utilization.
• Participants/setting: This prospective cohort study took place at a tertiary academic medical center and included 6424 patients admitted to the general internal medicine service between April 2016 and March 2018.
• Intervention: An intervention bundle, whose first components were implemented in July 2016, included computer order entry restrictions on repetitive laboratory testing, education, and audit-feedback.
• Measures: Data were extracted from the hospital electronic health record. The primary outcome was the number of routine blood tests (complete blood count, creatinine, and electrolytes) ordered per inpatient day.
• Analysis: Descriptive statistics were calculated for demographic variables. We used statistical process control charts to compare the baseline period (April 2016-June 2017) and the intervention period (July 2017-March 2018) for the primary outcome.
• Results: The mean number of combined routine laboratory tests ordered per inpatient day decreased from 1.19 (SD, 0.21) tests to 1.11 (SD, 0.05), a relative reduction of 6.7% (P < 0.0001). Mean cost per case related to laboratory tests decreased from $17.24 in the pre-intervention period to $16.17 in the post-intervention period (relative reduction of 6.2%). This resulted in savings of $26,851 in the intervention year.
• Conclusion: A laboratory intervention bundle was associated with small reductions in testing and costs. A routine test performed less than once per inpatient day may not be clinically appropriate or possible.

Keywords: utilization; clinical costs; quality improvement; QI intervention; internal medicine; inpatient.

Routine laboratory blood testing is a commonly used diagnostic tool that physicians rely on to provide patient care. Although routine blood testing represents less than 5% of most hospital budgets, routine use and over-reliance on testing among physicians makes it a target of cost-reduction efforts.^1-3 A variety of interventions have been proposed to reduce inappropriate laboratory tests, with varying results.^1,4-6 Successful interventions include providing physicians with fee data associated with ordered laboratory tests, unbundling panels of tests, and multicomponent interventions.⁶ We conducted a multifaceted quality improvement study to promote and develop interventions to adopt appropriate blood test ordering practices.

Methods

Setting

This prospective cohort study took place at Mount Sinai Hospital, a 443-bed academic hospital affiliated with the University of Toronto, where more than 2400 learners rotate through annually. The study was approved by the Mount Sinai Hospital Research Ethics Board.

Participants

We included all inpatient admissions to the general internal medicine service between April 2016 and March 2018. Exclusion criteria included a length of stay (LOS) longer than 365 days and admission to a critical care unit. Patients with more than 1 admission were counted as separate hospital inpatient visits.

Intervention

Based on internal data, we targeted the top 3 most frequently ordered routine blood tests: complete blood count (CBC), creatinine, and electrolytes. Trainee interviews revealed that habit, bundled order sets, and fear of “missing something” contributed to inappropriate routine blood test ordering. Based on these root causes, we used the Model for Improvement to iteratively develop a multimodal intervention that began in July 2016.^7,8 This included a change to the computerized provider order entry (CPOE) to nudge clinicians to a restrictive ordering strategy by substituting the “Daily x3” frequency of blood test ordering with a “Daily x1” option on a pick list of order options. Clinicians could still order daily routine blood tests for any specified duration, but would have to do so by manually changing the default setting within the CPOE.

From July 2017 to March 2018, the research team educated residents on appropriate laboratory test ordering and provided audit and feedback data to the clinicians. Diagnostic uncertainty was addressed in teaching sessions. Attending physicians were surveyed on appropriate indications for daily laboratory testing for each of CBC, electrolytes, and creatinine. Appropriate indications (Figure 1) were displayed in visible clinical areas and incorporated into teaching sessions.⁹

Clinician teams received real-time performance data on their routine blood test ordering patterns compared with an institutional benchmark. Bar graphs of blood work ordering rates (sum of CBCs, creatinine, and electrolytes ordered for all patients on a given team divided by the total LOS for all patients) were distributed to each internal medicine team via email every 2 weeks (Figure 2).^1,10-12

Data Collection and Analysis

Data were extracted from the hospital electronic health record (EHR). The primary outcome was the number of routine blood tests (CBC, creatinine, and electrolytes) ordered per inpatient day. Descriptive statistics were calculated for demographic variables. We used statistical process control (SPC) charts to compare the baseline period (April 2016-June 2017) and the intervention period (July 2017-March 2018) for the primary outcome. SPC charts display process changes over time. Data are plotted in chronological order, with the central line representing the outcome mean, an upper line representing the upper control limit, and a lower line representing the lower control limit. The upper and lower limits were set at 3δ, which correspond to 3 standard deviations above and below the mean. Six successive points above or beyond the mean suggests “special cause variation,” indicating that observed results are unlikely due to secular trends. SPC charts are commonly used quality tools for process improvement as well as research.^13-16 These charts were created using QI Macros SPC software for Excel V. 2012.07 (KnowWare International, Denver, CO).

The direct cost of each laboratory test was acquired from the hospital laboratory department. The cost of each laboratory test (CBC = $7.54/test, electrolytes = $2.04/test, creatinine = $1.28/test, in Canadian dollars) was subsequently added together and multiplied by the pre- and post-intervention difference of total blood tests saved per inpatient day and then multiplied by 365 to arrive at an estimated cost savings per year.

Results

Over the study period, there were 6424 unique patient admissions on the general internal medicine service, with a median LOS of 3.5 days (Table).

The majority of inpatient visits had at least 1 test of CBC (80%; mean, 3.6 tests/visit), creatinine (79.3%; mean, 3.5 tests/visit), or electrolytes (81.6%; mean, 3.9 tests/visit) completed. In total, 56,767 laboratory tests were ordered.

Following the intervention, there was a reduction in both rates of routine blood test orders and their associated costs, with a shift below the mean. The mean number of tests ordered (combined CBC, creatinine, and electrolytes) per inpatient day decreased from 1.19 (SD, 0.21) in the pre-intervention period to 1.11 (SD, 0.05) in the post-intervention period (P < 0.0001), representing a 6.7% relative reduction (Figure 3). We observed a 6.2% relative reduction in costs per inpatient day, translating to a total savings of $26,851 over 1 year for the intervention period.

Discussion

Our study suggests that a multimodal intervention, including CPOE restrictions, resident education with posters, and audit and feedback strategies, can reduce lab test ordering on general internal medicine wards. This finding is similar to those of previous studies using a similar intervention, although different laboratory tests were targeted.^{1,2,5,6,10,17}

Our study found lower test result reductions than those reported by a previous study, which reported a relative reduction of 17% to 30%,¹⁸ and by another investigation that was conducted recently in a similar setting.¹⁷ In the latter study, reductions in laboratory testing were mostly found in nonroutine tests, and no significant improvements were noted in CBC, electrolytes, and creatine, the 3 tests we studied over the same duration.¹⁷ This may represent a ceiling effect to reducing laboratory testing, and efforts to reduce CBC, electrolytes, and creatinine testing beyond 0.3 to 0.4 tests per inpatient day (or combined 1.16 tests per inpatient day) may not be clinically appropriate or possible. This information can guide institutions to include other areas of overuse based on rates of utilization in order to maximize the benefits from a resource intensive intervention.

There are a number of limitations that merit discussion. First, observational studies do not demonstrate causation; however, to our knowledge, there were no other co-interventions that were being conducted during the study duration. One important note is that our project’s intervention began in July, at which point there are new internal medicine residents beginning their training. As the concept of resource allocation becomes more important, medical schools are spending more time educating students about Choosing Wisely, and, therefore, newer cohorts of residents may be more cognizant of appropriate blood testing. Second, this is a single-center study, limiting generalizability; however, we note that many other centers have reported similar findings. Another limitation is that we do not know whether there were any adverse clinical events associated with blood work ordering that was too restrictive, although informal tracking of STAT laboratory testing remained stable throughout the study period. It is important to ensure that blood work is ordered in moderation and tailored to patients using one’s clinical judgment.

Future Directions

We observed modest reductions in the quantity and costs associated with a quality improvement intervention aimed at reducing routine blood testing. A baseline rate of laboratory testing of less than 1 test per inpatient day may require including other target tests to drive down absolute utilization.

Corresponding author: Christine Soong, MD, MSc, 433-600 University Avenue, Toronto, Ontario, Canada M5G 1X5; [email protected].

Financial disclosures: None.

Delayed health care brought on by the pandemic is taking its toll on patients, a survey of primary care doctors shows. 

More than half (56%) of responding clinicians reported seeing a decline in patient health because of delayed or inaccessible care amid the pandemic, according to the results of the latest survey by the Larry A. Green Center and the Primary Care Collaborative. The survey was conducted in mid-October and the results were published online Nov. 17.  

In addition, 37% of respondents said their patients with chronic conditions showed “noticeably worse health resulting from the pandemic.” And a resounding 85% said patient mental health had worsened. 

“I think it’s worse than we thought,” said Rebecca Etz, PhD, codirector of the Larry Green Center. “It’s the outcome of not sufficiently sending resources to primary care either before or during the pandemic.” According to Dr. Etz, survey respondents noted substantial increases in patient weight gain as well as weight loss, anxiety and depression, sleep issues, domestic abuse, and poor oral and eye health, among others.

One clinician from Pennsylvania wrote: “Patients are becoming sicker during the pandemic. I’m seeing more uncontrolled [diabetes]and new [patients with diabetes]. They prefer telehealth yet [have] no access to glucose monitoring or a blood pressure cuff. I am concerned about patients’ isolation and mental health. People are delaying care.”

Now, with COVID numbers peaking across much of the country, many clinicians are trying to close the gap in care with telehealth – something they’re more prepared to do now than they were in March. Over two-thirds of practices are using telehealth for visits to keep up with patients who have stable chronic conditions, according to the survey.

Over 60% of physicians report using telehealth for mental health visits. But a much smaller number – only 16% of respondents – said their practice had added staff to help manage the rising number of behavioral and mental health cases. About one-third (35%) of practices say they’re not financially able to take on new staff.

“We’ve been looking for more ways for patients to do self-support. A big part of chronic disease is health behaviors,” Alex Krist, MD, MPH, a family doctor in Fairfax, Va., and chairperson of the U.S. Preventive Services Task Force, said in an interview. And unfortunately, on top of limited access to basic care, healthy habits that are essential to managing many chronic conditions have become more difficult and less consistent during the pandemic. 

The survey – the 22nd iteration in a series of surveys the Green Center and the Primary Care Collaborative have conducted – received 580 respondents from 47 states and Guam. Over two-thirds of respondents were primary care physicians (MDs and DOs). Over half were owners, partners, or employees of a private practice, 66% of which were family medicine practices. And one fifth of respondents provided care in a rural area.

Funding and support for primary care has been wildly insufficient, Dr. Etz said in an interview. If that doesn’t change, patient health, clinic staffing, and public health strategies amid the pandemic will continue to suffer.

“When you think of the COVID vaccine, who do you think is going to be sending that out?” Dr. Etz asked. “If we don’t bolster primary care now how are they going to handle that.”
 

A version of this article originally appeared on Medscape.com.

Delayed health care brought on by the pandemic is taking its toll on patients, a survey of primary care doctors shows. 

More than half (56%) of responding clinicians reported seeing a decline in patient health because of delayed or inaccessible care amid the pandemic, according to the results of the latest survey by the Larry A. Green Center and the Primary Care Collaborative. The survey was conducted in mid-October and the results were published online Nov. 17.  

In addition, 37% of respondents said their patients with chronic conditions showed “noticeably worse health resulting from the pandemic.” And a resounding 85% said patient mental health had worsened. 

“I think it’s worse than we thought,” said Rebecca Etz, PhD, codirector of the Larry Green Center. “It’s the outcome of not sufficiently sending resources to primary care either before or during the pandemic.” According to Dr. Etz, survey respondents noted substantial increases in patient weight gain as well as weight loss, anxiety and depression, sleep issues, domestic abuse, and poor oral and eye health, among others.

One clinician from Pennsylvania wrote: “Patients are becoming sicker during the pandemic. I’m seeing more uncontrolled [diabetes]and new [patients with diabetes]. They prefer telehealth yet [have] no access to glucose monitoring or a blood pressure cuff. I am concerned about patients’ isolation and mental health. People are delaying care.”

Now, with COVID numbers peaking across much of the country, many clinicians are trying to close the gap in care with telehealth – something they’re more prepared to do now than they were in March. Over two-thirds of practices are using telehealth for visits to keep up with patients who have stable chronic conditions, according to the survey.

Over 60% of physicians report using telehealth for mental health visits. But a much smaller number – only 16% of respondents – said their practice had added staff to help manage the rising number of behavioral and mental health cases. About one-third (35%) of practices say they’re not financially able to take on new staff.

“We’ve been looking for more ways for patients to do self-support. A big part of chronic disease is health behaviors,” Alex Krist, MD, MPH, a family doctor in Fairfax, Va., and chairperson of the U.S. Preventive Services Task Force, said in an interview. And unfortunately, on top of limited access to basic care, healthy habits that are essential to managing many chronic conditions have become more difficult and less consistent during the pandemic. 

The survey – the 22nd iteration in a series of surveys the Green Center and the Primary Care Collaborative have conducted – received 580 respondents from 47 states and Guam. Over two-thirds of respondents were primary care physicians (MDs and DOs). Over half were owners, partners, or employees of a private practice, 66% of which were family medicine practices. And one fifth of respondents provided care in a rural area.

Funding and support for primary care has been wildly insufficient, Dr. Etz said in an interview. If that doesn’t change, patient health, clinic staffing, and public health strategies amid the pandemic will continue to suffer.

“When you think of the COVID vaccine, who do you think is going to be sending that out?” Dr. Etz asked. “If we don’t bolster primary care now how are they going to handle that.”
 

A version of this article originally appeared on Medscape.com.

Delayed health care brought on by the pandemic is taking its toll on patients, a survey of primary care doctors shows. 

More than half (56%) of responding clinicians reported seeing a decline in patient health because of delayed or inaccessible care amid the pandemic, according to the results of the latest survey by the Larry A. Green Center and the Primary Care Collaborative. The survey was conducted in mid-October and the results were published online Nov. 17.  

In addition, 37% of respondents said their patients with chronic conditions showed “noticeably worse health resulting from the pandemic.” And a resounding 85% said patient mental health had worsened. 

“I think it’s worse than we thought,” said Rebecca Etz, PhD, codirector of the Larry Green Center. “It’s the outcome of not sufficiently sending resources to primary care either before or during the pandemic.” According to Dr. Etz, survey respondents noted substantial increases in patient weight gain as well as weight loss, anxiety and depression, sleep issues, domestic abuse, and poor oral and eye health, among others.

One clinician from Pennsylvania wrote: “Patients are becoming sicker during the pandemic. I’m seeing more uncontrolled [diabetes]and new [patients with diabetes]. They prefer telehealth yet [have] no access to glucose monitoring or a blood pressure cuff. I am concerned about patients’ isolation and mental health. People are delaying care.”

Now, with COVID numbers peaking across much of the country, many clinicians are trying to close the gap in care with telehealth – something they’re more prepared to do now than they were in March. Over two-thirds of practices are using telehealth for visits to keep up with patients who have stable chronic conditions, according to the survey.

Over 60% of physicians report using telehealth for mental health visits. But a much smaller number – only 16% of respondents – said their practice had added staff to help manage the rising number of behavioral and mental health cases. About one-third (35%) of practices say they’re not financially able to take on new staff.

“We’ve been looking for more ways for patients to do self-support. A big part of chronic disease is health behaviors,” Alex Krist, MD, MPH, a family doctor in Fairfax, Va., and chairperson of the U.S. Preventive Services Task Force, said in an interview. And unfortunately, on top of limited access to basic care, healthy habits that are essential to managing many chronic conditions have become more difficult and less consistent during the pandemic. 

The survey – the 22nd iteration in a series of surveys the Green Center and the Primary Care Collaborative have conducted – received 580 respondents from 47 states and Guam. Over two-thirds of respondents were primary care physicians (MDs and DOs). Over half were owners, partners, or employees of a private practice, 66% of which were family medicine practices. And one fifth of respondents provided care in a rural area.

Funding and support for primary care has been wildly insufficient, Dr. Etz said in an interview. If that doesn’t change, patient health, clinic staffing, and public health strategies amid the pandemic will continue to suffer.

“When you think of the COVID vaccine, who do you think is going to be sending that out?” Dr. Etz asked. “If we don’t bolster primary care now how are they going to handle that.”
 

A version of this article originally appeared on Medscape.com.

Anti-kickback statutes (AKSs) were originally enacted in 1931 to stop Great Depression–era employers from circumventing wage provisions in federal contracts. Since its enactment, AKSs’ main focus has changed and is currently aimed at the health care industry. In addition to AKSs, Stark laws were enacted over 30 years ago to address physician self-referral of Medicare patients. Both laws comprise the government’s main tools for fighting fraud, waste, and abuse.

Dr. Losurdo is the AGA’s Alternate Advisor to the American Medical Association’s CPT Editorial Panel, a member of the AGA Practice Management and Economics Committee’s Coverage and Reimbursement Subcommittee and is a partner with Elgin Gastro Endoscopy, who owns and ASC, and Managing Partner and Medical Director of Illinois Gastroenterology Group/GI Alliance, Elgin, Ill.

This story was updated on 12/11/2020.

Anti-kickback statutes (AKSs) were originally enacted in 1931 to stop Great Depression–era employers from circumventing wage provisions in federal contracts. Since its enactment, AKSs’ main focus has changed and is currently aimed at the health care industry. In addition to AKSs, Stark laws were enacted over 30 years ago to address physician self-referral of Medicare patients. Both laws comprise the government’s main tools for fighting fraud, waste, and abuse.

Dr. Losurdo is the AGA’s Alternate Advisor to the American Medical Association’s CPT Editorial Panel, a member of the AGA Practice Management and Economics Committee’s Coverage and Reimbursement Subcommittee and is a partner with Elgin Gastro Endoscopy, who owns and ASC, and Managing Partner and Medical Director of Illinois Gastroenterology Group/GI Alliance, Elgin, Ill.

This story was updated on 12/11/2020.

Anti-kickback statutes (AKSs) were originally enacted in 1931 to stop Great Depression–era employers from circumventing wage provisions in federal contracts. Since its enactment, AKSs’ main focus has changed and is currently aimed at the health care industry. In addition to AKSs, Stark laws were enacted over 30 years ago to address physician self-referral of Medicare patients. Both laws comprise the government’s main tools for fighting fraud, waste, and abuse.

Dr. Losurdo is the AGA’s Alternate Advisor to the American Medical Association’s CPT Editorial Panel, a member of the AGA Practice Management and Economics Committee’s Coverage and Reimbursement Subcommittee and is a partner with Elgin Gastro Endoscopy, who owns and ASC, and Managing Partner and Medical Director of Illinois Gastroenterology Group/GI Alliance, Elgin, Ill.

This story was updated on 12/11/2020.

From the Senior Health Program, Providence Health & Services, Oregon, Portland, OR.

Abstract

Background: Approximately 51 million adults in the United States are 65 years of age or older, yet few geriatric-trained primary care providers (PCP) serve this population. The Age-Friendly Health System framework, consisting of evidence-based 4M care (Mobility, Medication, Mentation, and what Matters), encourages all PCPs to assess mobility in older adults.

Objective: To improve PCP knowledge, confidence, and clinical practice in assessing and managing fall risk.

Methods: A 1-week educational session focusing on mobility (part of a 4-week Geriatric Mini-Fellowship) for 6 selected PCPs from a large health care system was conducted to increase knowledge and ability to address fall risk in older adults. The week included learning and practicing a Fall Risk Management Plan (FRMP) algorithm, including planning for their own practice changes. Pre- and post-test surveys assessed changes in knowledge and confidence. Patient data were compared 12 months before and after training to evaluate PCP adoption of FRMP components.

Results: The training increased provider knowledge and confidence. The trained PCPs were 1.7 times more likely to screen for fall risk; 3.6 times more likely to discuss fall risk; and 5.8 times more likely to assess orthostatic blood pressure in their 65+ patients after the mini-fellowship. In high-risk patients, they were 4.1 times more likely to discuss fall risk and 6.3 times more likely to assess orthostatic blood pressure than their nontrained peers. Changes in physical therapy referral rates were not observed.

Conclusions: In-depth, skills-based geriatric educational sessions improved PCPs’ knowledge and confidence and also improved their fall risk management practices for their older patients.

Keywords: geriatrics; guidelines; Age-Friendly Health System; 4M; workforce training; practice change; fellowship.

The US population is aging rapidly. People aged 85 years and older are the largest-growing segment of the US population, and this segment is expected to increase by 123% by 2040.¹ Caregiving needs increase with age as older adults develop more chronic conditions, such as hypertension, heart disease, arthritis, and dementia. However, even with increasing morbidity and dependence, a majority of older adults still live in the community rather than in institutional settings.² These older adults seek medical care more frequently than younger people, with about 22% of patients 75 years and older having 10 or more health care visits in the previous 12 months. By 2040, nearly a quarter of the US population is expected to be 65 or older, with many of these older adults seeking regular primary care from providers who do not have formal training in the care of a population with multiple complex, chronic health conditions and increased caregiving needs.¹

Despite this growing demand for health care professionals trained in the care of older adults, access to these types of clinicians is limited. In 2018, there were roughly 7000 certified geriatricians, with only 3600 of them practicing full-time.^3,4 Similarly, of 290,000 certified nurse practitioners (NPs), about 9% of them have geriatric certification.⁵ Geriatricians, medical doctors trained in the care of older adults, and geriatric-trained NPs are part of a cadre of a geriatric-trained workforce that provides unique expertise in caring for older adults with chronic and advanced illness. They know how to manage multiple, complex geriatric syndromes like falls, dementia, and polypharmacy; understand and maximize team-based care; and focus on caring for an older person with a goal-centered versus a disease-centered approach.⁶

Broadly, geriatric care includes a spectrum of adults, from those who are aging healthfully to those who are the frailest. Research has suggested that approximately 30% of older adults need care by a geriatric-trained clinician, with the oldest and frailest patients needing more clinician time for assessment and treatment, care coordination, and coaching of caregivers.⁷ With this assumption in mind, it is projected that by 2025, there will be a national shortage of 26,980 geriatricians, with the western United States disproportionately affected by this shortage.⁴Rather than lamenting this shortage, Tinetti recommends a new path forward: “Our mission should not be to train enough geriatricians to provide direct care, but rather to ensure that every clinician caring for older adults is competent in geriatric principles and practices.”⁸ Sometimes called ”geriatricizing,” the idea is to use existing geriatric providers as a small elite training force to infuse geriatric principles and skills across their colleagues in primary care and other disciplines.^8,9 Efforts of the American Geriatrics Society (AGS), with support from the John A. Hartford Foundation (JAHF), have been successful in developing geriatric training across multiple specialties, including surgery, orthopedics, and emergency medicine (www.americangeriatrics.org/programs/geriatrics-specialists-initiative).

The Age-Friendly Health System and 4M Model

To help augment this idea of equipping health care systems and their clinicians with more readily available geriatric knowledge, skills, and tools, the JAHF, along with the Institute for Healthcare Improvement (IHI), created the Age-Friendly Health System (AFHS) paradigm in 2015.¹⁰ Using the 4M model, the AFHS initiative established a set of evidence-based geriatric priorities and interventions meant to improve the care of older adults, reduce harm and duplication, and provide a framework for engaging leadership, clinical teams, and operational systems across inpatient and ambulatory settings.¹¹ Mobility, including fall risk screening and intervention, is 1 of the 4M foundational elements of the Age-Friendly model. In addition to Mobility, the 4M model also includes 3 other key geriatric domains: Mentation (dementia, depression, and delirium), Medication (high-risk medications, polypharmacy, and deprescribing), and What Matters (goals of care conversations and understanding quality of life for older patients).¹¹ The 4M initiative encourages adoption of a geriatric lens that looks across chronic conditions and accounts for the interplay among geriatric syndromes, such as falls, cognitive impairment, and frailty, in order to provide care better tailored to what the patient needs and desires.¹² IHI and JAHF have targeted the adoption of the 4M model by 20% of US health care systems by 2020.¹¹

Mini-Fellowship and Mobility Week

To bolster geriatric skills among community-based primary care providers (PCPs), we initiated a Geriatric Mini-Fellowship, a 4-week condensed curriculum taught over 6 months. Each week focuses on 1 of the age-friendly 4Ms, with the goal of increasing the knowledge, self-efficacy, skills, and competencies of the participating PCPs (called “fellow” hereafter) and at the same time, equipping each to become a champion of geriatric practice. This article focuses on the Mobility week, the second week of the mini-fellowship, and the effect of the week on the fellows’ practice changes.

To construct the Mobility week’s curriculum with a focus on the ambulatory setting, we relied upon national evidence-based work in fall risk management. The Centers for Disease Control and Prevention (CDC) has made fall risk screening and management in primary care a high priority. Using the clinical practice guidelines for managing fall risk developed by the American and British Geriatrics Societies (AGS/BGS), the CDC developed the Stopping Elderly Accidents, Deaths, and Injuries (STEADI) toolkit.¹³ Foundational to the toolkit is the validated 12-item Stay Independent falls screening questionnaire (STEADI questionnaire).¹⁴ Patients who score 4 or higher (out of a total score of 14) on the questionnaire are considered at increased risk of falling. The CDC has developed a clinical algorithm that guides clinical teams through screening and assessment to help identify appropriate interventions to target specific risk factors. Research has clearly established that a multifactorial approach to fall risk intervention can be successful in reducing fall risk by as much as 25%.^15-17

The significant morbidity and mortality caused by falls make training nongeriatrician clinicians on how to better address fall risk imperative. More than 25% of older adults fall each year.¹⁸ These falls contribute to rising rates of fall-related deaths,¹⁹ emergency department (ED) visits,²⁰ and hospital readmissions.²¹ Initiatives like the AFHS focus on mobility and the CDC’s development of supporting clinical materials²² aim to improve primary care adoption of fall risk screening and intervention practices.^23,24 The epidemic of falls must compel all PCPs, not just those practicing geriatrics, to make discussing and addressing fall risk and falls a priority.

Methods

Setting

This project took place as part of a regional primary care effort in Oregon. Providence Health & Services-Oregon is part of a multi-state integrated health care system in the western United States whose PCPs serve more than 80,000 patients aged 65 years and older per year; these patients comprise 38% of the system’s office visits each year. Regionally, there are 47 family and internal medicine clinics employing roughly 290 providers (physicians, NPs, and physician assistants). The organization has only 4 PCPs trained in geriatrics and does not offer any geriatric clinical consultation services. Six PCPs from different clinics, representing both rural and urban settings, are chosen to participate in the geriatric mini-fellowship each year.

This project was conducted as a quality improvement initiative within the organization and did not constitute human subjects research. It was not conducted under the oversight of the Institutional Review Board.

Intervention

The mini-fellowship was taught in 4 1-week blocks between April and October 2018, with a curriculum designed to be interactive and practical. The faculty was intentionally interdisciplinary to teach and model team-based practice. Each week participants were excused from their clinical practice. Approximately 160 hours of continuing medical education credits were awarded for the full mini-fellowship. As part of each weekly session, a performance improvement project (PIP) focused on that week’s topic (1 of the 4Ms) was developed by the fellow and their team members to incorporate the mini-fellowship learnings into their clinic workflows. Fellows also had 2 hours per week of dedicated administration time for a year, outside the fellowship, to work on their PIP and 4M practice changes within their clinic.

Provider Education

The week for mobility training comprised 4 daylong sessions. The first 2 days were spent learning about the epidemiology of falls; risk factors for falling; how to conduct a thorough history and assessment of fall risk; and how to create a prioritized Fall Risk Management Plan (FRMP) to decrease a patient’s individual fall risk through tailored interventions. The FRMP was adapted from the CDC STEADI toolkit.¹³ Core faculty were 2 geriatric-trained providers (NP and physician) and a physical therapist (PT) specializing in fall prevention.

On the third day, fellows took part in a simulated fall risk clinic, in which older adults volunteered to be patient partners, providing an opportunity to apply learnings from days 1 and 2. The clinic included the fellow observing a PT complete a mobility assessment and a pharmacist conduct a high-risk medication review. The fellow synthesized the findings of the mobility assessment and medication review, as well as their own history and assessment, to create a summary of fall risk recommendations to discuss with their volunteer patient partner. The fellows were observed and evaluated in their skills by their patient partner, course faculty, and another fellow. The patient partners, and their assigned fellow, also participated in a 45-minute fall risk presentation, led by a nurse.

On the fourth day, the fellows were joined by select clinic partners, including nurses, pharmacists, and/or medical assistants. The session included discussions among each fellow’s clinical team regarding the current state of fall risk efforts at their clinic, an analysis of barriers, and identification of opportunities to improve workflows and screening rates. Each fellow took with them an action plan tailored to their clinic to improve fall risk management practices, starting with the fellow’s own practice.

Fall Risk Management Plan

The educational sessions introduced the fellows to the FRMP. The FRMP, adapted from the STEADI toolkit, includes a process for fall risk screening (Figure 1) and stratifying a patient’s risk based on their STEADI score in order to promote 3 priority assessments (gait evaluation with PT referral if appropriate; orthostatic blood pressure; and high-risk medication review; Figure 2). Initial actions based on these priority assessments were followed over time, with additional fall risk interventions added as clinically indicated.²⁵ The FRMP is intended to be used during routine office visits, Medicare annual wellness visits, or office visits focused on fall risk or related medical disorders (ie, fall risk visits.)

Providers and their teams were encouraged to spread out fall-related conversations with their patients over multiple visits, since many patients have multiple fall risk factors at play, in addition to other chronic medical issues, and since many interventions often require behavior changes on the part of the patient. Providers also had access to fall-related electronic health record (EHR) templates as well as a comprehensive, internal fall risk management website that included assessment tools, evidence-based resources, and patient handouts.

Assessment and Measurements

We assessed provider knowledge and comfort in their fall risk evaluation and management skills before and after the educational intervention using an 11-item multiple-choice questionnaire and a 4-item confidence questionnaire. The confidence questions used a 7-point Likert scale, with 0 indicating “no confidence” and 7 indicating ”lots of confidence.” The questions were administered via a paper survey. Qualitative comments were derived from evaluations completed at the end of the week.

The fellows’ practice of fall risk screening and management was studied from May 2018, at the completion of Mobility week, to May 2019 for the post-intervention period. A 1-year timeframe before May 2018 was used as the pre-intervention period. Eligible visit types, during which we assumed fall risk was discussed, were any office visits for patients 65+ completed by the patients’ PCPs that used fall risk as a reason for the visit or had a fall-related diagnosis code. Fall risk visits performed by other clinic providers were not counted.

Of those patients who had fall risk screenings completed and were determined to be high risk (STEADI score ≥ 4), data were analyzed to determine whether these patients had any fall-related follow-up visits to their PCP within 60 days of the STEADI screening. For these high-risk patients, data were studied to understand whether orthostatic blood pressure measurements were performed (as documented in a flowsheet) and whether a PT referral was placed. These data were compared with those from providers who practiced in clinics within the same system but who did not participate in the mini-fellowship. Data were obtained from the organization’s EHR. Additional data were measured to evaluate patterns of deprescribing of select high-risk medications, but these data are not included in this analysis.

Analysis

A paired-samples t test was used to measure changes in provider confidence levels. Data were aggregated across fellows, resulting in a mean. A chi-square test of independence was performed to examine the relationship between rates of FRMP adoption by select provider groups. Analysis included a pre- and post-intervention assessment of the fellows’ adoption of FRMP practices, as well as a comparison between the fellows’ practice patterns and those of a control group of PCPs in the organization’s other clinics who did not participate in the mini-fellowship (nontrained control group). Excluded from the control group were providers from the same clinic as the fellows; providers in clinics with a geriatric-trained provider on staff; and clinics outside of the Portland metro and Medford service areas. We used an alpha level of 0.05 for all statistical tests.

Data from 5 providers were included in the analysis of the FRMP adoption. The sixth provider changed practice settings from the clinic to the ED after completing the fellowship; her patient data were not included in the FRMP part of the analysis. EHR data included data on all visits of patients 65+, as well as data for just those 65+ patients who had been identified as being at high risk to fall based on a STEADI score of 4 or higher.

Results

Provider Questionnaire

All 6 providers responded to the pre-intervention and post-intervention tests. For the knowledge questions, fellows, as a composite, correctly answered 57% of the questions before the intervention and 79% after the intervention. Provider confidence level in delivering fall risk care was measured prior to the training (mean, 4.12 [SD, 0.62]) and at the end of the training (mean, 6.47 [SD, 0.45]), demonstrating a significant increase in confidence (t (5) = –10.46, P < 0.001).

Qualitative Comments

Providers also had the opportunity to provide comments on their experience during the Mobility week and at the end of 1 year. In general, the simulated interdisciplinary fall risk clinic was highly rated (“the highlight of the week”) as a practical strategy to embed learning principles. One fellow commented, “Putting the learning into practice helps solidify it in my brain.” Fellows also appreciated the opportunity to learn and meet with their clinic colleagues to begin work on a fall-risk focused PIP and to “have a framework for what to do for people who screen positive [for fall risk].”

FRMP Adoption

A comparison of the care the fellows provided to their patients 65+ in the 12 months pre- and post-training shows the fellows demonstrated significant changes in practice patterns. The fellows were 1.7 times more likely to screen for fall risk; 3.6 times more likely to discuss fall risk; and 5.8 times more likely to check orthostatic blood pressure than prior to the mini-fellowship (Table 1).

The control providers also demonstrated significant increases in fall risk screening and discussion of fall risk between the pre- and post-intervention periods; however, the relative risk (RR) was between 1.10 and 1.13 for this group. For the control group, checking orthostatic blood pressure did not significantly change. In the 12 months after training (Table 2), the fellows were 4.2 times more likely to discuss fall risk and almost 5 times more likely to check orthostatic blood pressure than their nontrained peers for all of their patients 65+, regardless of their risk to fall.

As shown in Table 3, for those patients determined to be at high risk of falling (STEADI score ≥ 4), fellows showed statistically significant increases in fall risk visits (RR, 3.02) and assessment of orthostatic blood pressure (RR, 10.68) before and after the mini-fellowship. The control providers did not show any changes in practice patterns between the pre- and post-period among patients at high risk to fall.

Neither the fellows nor the control group showed changes in patterns of referral to PT. In comparing the 2 groups in the 12 months after training (Table 4), for their patients at risk of falling, the fellows were 4 times more likely to complete fall risk visits and over 6 times more likely to assess orthostatic blood pressure than their nontrained peers. Subgroup analysis of the 75+ population revealed similar trends and significance, but these results are not included here.

Discussion

This study aimed to improve not only providers’ knowledge and confidence in caring for older adults at increased risk to fall, but also their clinical practice in assessing and managing fall risk. In addition to improved knowledge and confidence, we found that the fellows increased their discussion of fall risk (through fall risk visits) and their assessment of orthostatic blood pressure for all of their patients, not just for those identified at increased risk to fall. This improvement held true for the fellows themselves before and after the intervention, but also as compared to their nontrained peers. These practice improvements for all of their 65+ patients, not just those identified as being at high risk to fall, are especially important, since studies indicate that early screening and intervention can help identify people at risk and prevent future falls.¹⁵

We were surprised that there were no significant differences in PT referrals made by the trained fellows, but this finding may have been confounded by the fact that the data included all PT referrals, regardless of diagnosis, not just those referrals that were fall-related. Furthermore, our baseline PT referral rates, at 39% for the intervention group and 42% for the control group, are higher than national data when looking at rehabilitation use by older adults.²⁶

In comparison to a study evaluating the occurrence of fall risk–related clinical practice in primary care before any fall-related educational intervention, orthostatics were checked less frequently in our study (10% versus 30%) and there were fewer PT referrals (42%–44% versus 53%).²⁷ However, the Phelan study took place in patients who had actually had a fall, rather than just having a higher risk for a fall, and was based on detailed chart review. Other studies^23,24 found higher rates of fall risk interventions, but did not break out PT referrals specifically.

In terms of the educational intervention itself, most studies of geriatric education interventions have measured changes in knowledge, confidence, or self-efficacy as they relate to geriatric competence,^28-30 and do not measure practice change as an outcome outside of intent to change or self-reported practice change.^31,32 In general, practice change or longer-term health care–related outcomes have not been studied. Additionally, a range of dosages of educational interventions has been studied, from 1-hour lunchtime presentations^23,32 to half-day²⁹ or several half-day workshops,²⁸ up to 160 hours over 10 months³⁰ or 5 weekends over 6 months.³¹ The duration of our entire intervention at 160 hours over 6 months would be considered on the upper end of dosing relative to these studies, with our Mobility week intervention comprising 32 hours during 1 week. In the Warshaw study, despite 107 1-hour sessions being taught to over 60 physicians in 16 practices over 4 years, only 2 practices ultimately initiated any practice change projects.³² We believe that only curricula that embed practice change skills and opportunities, at a significant enough dose, can actually impact practice change in a sustainable manner.

Knowledge and skill acquisition among individual providers does not take place to a sufficient degree in the current health care arena, which is focused on productivity and short visit times. Consistent with other studies, we included interdisciplinary members of the primary care team for part of the mini-fellowship, although other studies used models that train across disciplines for the entirety of the learning experience.^28-30,33 Our educational model was strengthened by including other professionals to provide some of the education and model the ideal geriatric team, including PT, occupational therapy, and pharmacy, for the week on mobility.

Most studies exploring interventions through geriatric educational initiatives are conducted within academic institutions, with a primary focus on physician faculty and, by extension, their teaching of residents and others.^34,35 We believe our integrated model, which is steeped in community-based primary care practices like Lam’s,³¹ offers the greatest outreach to large community-based care systems and their patients. Training providers to work with their teams to change their own practices first gives skills and expertise that help further establish them as geriatric champions within their practices, laying the groundwork for more widespread practice change at their clinics.

Limitations

In addition to the limitations described above relating to the capture of PT referrals, other limitations included the relatively short time period for follow-up data as well as the small size of the intervention group. However, we found value in the instructional depth that the small group size allowed.

While the nontrained providers did show some improvement during the same period, we believe the relative risk was not clinically significant. We suspect that the larger health system efforts to standardize screening of patients 65+ across all clinics as a core quality metric confounded these results. The data analysis also included only fall-related patient visits that occurred with a provider who was that patient’s PCP, which could have missed visits done by other PCP colleagues, RNs, or pharmacists in the same clinic, thus undercounting the true number of fall-related visits. Furthermore, counting of fall-related interventions relied upon providers documenting consistently in the EHR, which could also lead to under-represention of fall risk clinical efforts.

The data presented, while encouraging, do not reflect clinic-wide practice change patterns and are considered only proximate outcomes rather than more long-term or cost-related outcomes, as would be captured by fall-related utilization measures like emergency room visits and hospitalizations. We expect to evaluate the broader impact and these value-based outcomes in the future. All providers and teams were from the same health care system, which may not allow our results to transfer to other organizations or regions of clinical practice.

Summary

This study demonstrates that an intensive mini-fellowship model of geriatrics training improved both knowledge and confidence in the realm of fall risk assessment and intervention among PCPs who had not been formally trained in geriatrics. More importantly, the training improved the fall-related care of their patients at increased risk to fall, but also of all of their older patients, with improvements in care measured up to a year after the mini-fellowship. Although this article only describes the work done as part of the Mobility aim of the 4M AFHS model, we believe the entire mini-fellowship curriculum offers the opportunity to “geriatricize” clinicians and their teams in learning geriatric principles and skills that they can translate into their practice in a sustainable way, as Tinetti encourages.⁸ Future study to evaluate other process outcomes more precisely, such as PT, as well as cost- and value-based outcomes, and the influence of trained providers on their clinic partners, will further establish the value proposition of targeted, disseminated, intensive geriatrics training of primary care clinicians as a strategy of age-friendly health systems as they work to improve the care of their older adults.

Acknowledgment: We are grateful for the dedication and hard work of the 2018 Geriatric Mini-Fellowship fellows at Providence Health & Services-Oregon who made this article possible. Thanks to Drs. Stephanie Cha, Emily Puukka-Clark, Laurie Dutkiewicz, Cara Ellis, Deb Frost, Jordan Roth, and Subhechchha Shah for promoting the AFHS work within their Providence Medical Group clinics and to PMG leadership and the fellows’ clinical teams for supporting the fellows, the AFHS work, and their older patients.

Corresponding author: Colleen M. Casey, PhD, ANP-BC, Providence Health & Services, Senior Health Program, 4400 NE Halsey, 5th Floor, Portland, OR 97213; [email protected].

Financial disclosures: None.

From the Senior Health Program, Providence Health & Services, Oregon, Portland, OR.

Abstract

Background: Approximately 51 million adults in the United States are 65 years of age or older, yet few geriatric-trained primary care providers (PCP) serve this population. The Age-Friendly Health System framework, consisting of evidence-based 4M care (Mobility, Medication, Mentation, and what Matters), encourages all PCPs to assess mobility in older adults.

Objective: To improve PCP knowledge, confidence, and clinical practice in assessing and managing fall risk.

Methods: A 1-week educational session focusing on mobility (part of a 4-week Geriatric Mini-Fellowship) for 6 selected PCPs from a large health care system was conducted to increase knowledge and ability to address fall risk in older adults. The week included learning and practicing a Fall Risk Management Plan (FRMP) algorithm, including planning for their own practice changes. Pre- and post-test surveys assessed changes in knowledge and confidence. Patient data were compared 12 months before and after training to evaluate PCP adoption of FRMP components.

Results: The training increased provider knowledge and confidence. The trained PCPs were 1.7 times more likely to screen for fall risk; 3.6 times more likely to discuss fall risk; and 5.8 times more likely to assess orthostatic blood pressure in their 65+ patients after the mini-fellowship. In high-risk patients, they were 4.1 times more likely to discuss fall risk and 6.3 times more likely to assess orthostatic blood pressure than their nontrained peers. Changes in physical therapy referral rates were not observed.

Conclusions: In-depth, skills-based geriatric educational sessions improved PCPs’ knowledge and confidence and also improved their fall risk management practices for their older patients.

Keywords: geriatrics; guidelines; Age-Friendly Health System; 4M; workforce training; practice change; fellowship.

The US population is aging rapidly. People aged 85 years and older are the largest-growing segment of the US population, and this segment is expected to increase by 123% by 2040.¹ Caregiving needs increase with age as older adults develop more chronic conditions, such as hypertension, heart disease, arthritis, and dementia. However, even with increasing morbidity and dependence, a majority of older adults still live in the community rather than in institutional settings.² These older adults seek medical care more frequently than younger people, with about 22% of patients 75 years and older having 10 or more health care visits in the previous 12 months. By 2040, nearly a quarter of the US population is expected to be 65 or older, with many of these older adults seeking regular primary care from providers who do not have formal training in the care of a population with multiple complex, chronic health conditions and increased caregiving needs.¹

Despite this growing demand for health care professionals trained in the care of older adults, access to these types of clinicians is limited. In 2018, there were roughly 7000 certified geriatricians, with only 3600 of them practicing full-time.^3,4 Similarly, of 290,000 certified nurse practitioners (NPs), about 9% of them have geriatric certification.⁵ Geriatricians, medical doctors trained in the care of older adults, and geriatric-trained NPs are part of a cadre of a geriatric-trained workforce that provides unique expertise in caring for older adults with chronic and advanced illness. They know how to manage multiple, complex geriatric syndromes like falls, dementia, and polypharmacy; understand and maximize team-based care; and focus on caring for an older person with a goal-centered versus a disease-centered approach.⁶

Broadly, geriatric care includes a spectrum of adults, from those who are aging healthfully to those who are the frailest. Research has suggested that approximately 30% of older adults need care by a geriatric-trained clinician, with the oldest and frailest patients needing more clinician time for assessment and treatment, care coordination, and coaching of caregivers.⁷ With this assumption in mind, it is projected that by 2025, there will be a national shortage of 26,980 geriatricians, with the western United States disproportionately affected by this shortage.⁴Rather than lamenting this shortage, Tinetti recommends a new path forward: “Our mission should not be to train enough geriatricians to provide direct care, but rather to ensure that every clinician caring for older adults is competent in geriatric principles and practices.”⁸ Sometimes called ”geriatricizing,” the idea is to use existing geriatric providers as a small elite training force to infuse geriatric principles and skills across their colleagues in primary care and other disciplines.^8,9 Efforts of the American Geriatrics Society (AGS), with support from the John A. Hartford Foundation (JAHF), have been successful in developing geriatric training across multiple specialties, including surgery, orthopedics, and emergency medicine (www.americangeriatrics.org/programs/geriatrics-specialists-initiative).

The Age-Friendly Health System and 4M Model

To help augment this idea of equipping health care systems and their clinicians with more readily available geriatric knowledge, skills, and tools, the JAHF, along with the Institute for Healthcare Improvement (IHI), created the Age-Friendly Health System (AFHS) paradigm in 2015.¹⁰ Using the 4M model, the AFHS initiative established a set of evidence-based geriatric priorities and interventions meant to improve the care of older adults, reduce harm and duplication, and provide a framework for engaging leadership, clinical teams, and operational systems across inpatient and ambulatory settings.¹¹ Mobility, including fall risk screening and intervention, is 1 of the 4M foundational elements of the Age-Friendly model. In addition to Mobility, the 4M model also includes 3 other key geriatric domains: Mentation (dementia, depression, and delirium), Medication (high-risk medications, polypharmacy, and deprescribing), and What Matters (goals of care conversations and understanding quality of life for older patients).¹¹ The 4M initiative encourages adoption of a geriatric lens that looks across chronic conditions and accounts for the interplay among geriatric syndromes, such as falls, cognitive impairment, and frailty, in order to provide care better tailored to what the patient needs and desires.¹² IHI and JAHF have targeted the adoption of the 4M model by 20% of US health care systems by 2020.¹¹

Mini-Fellowship and Mobility Week

To bolster geriatric skills among community-based primary care providers (PCPs), we initiated a Geriatric Mini-Fellowship, a 4-week condensed curriculum taught over 6 months. Each week focuses on 1 of the age-friendly 4Ms, with the goal of increasing the knowledge, self-efficacy, skills, and competencies of the participating PCPs (called “fellow” hereafter) and at the same time, equipping each to become a champion of geriatric practice. This article focuses on the Mobility week, the second week of the mini-fellowship, and the effect of the week on the fellows’ practice changes.

To construct the Mobility week’s curriculum with a focus on the ambulatory setting, we relied upon national evidence-based work in fall risk management. The Centers for Disease Control and Prevention (CDC) has made fall risk screening and management in primary care a high priority. Using the clinical practice guidelines for managing fall risk developed by the American and British Geriatrics Societies (AGS/BGS), the CDC developed the Stopping Elderly Accidents, Deaths, and Injuries (STEADI) toolkit.¹³ Foundational to the toolkit is the validated 12-item Stay Independent falls screening questionnaire (STEADI questionnaire).¹⁴ Patients who score 4 or higher (out of a total score of 14) on the questionnaire are considered at increased risk of falling. The CDC has developed a clinical algorithm that guides clinical teams through screening and assessment to help identify appropriate interventions to target specific risk factors. Research has clearly established that a multifactorial approach to fall risk intervention can be successful in reducing fall risk by as much as 25%.^15-17

The significant morbidity and mortality caused by falls make training nongeriatrician clinicians on how to better address fall risk imperative. More than 25% of older adults fall each year.¹⁸ These falls contribute to rising rates of fall-related deaths,¹⁹ emergency department (ED) visits,²⁰ and hospital readmissions.²¹ Initiatives like the AFHS focus on mobility and the CDC’s development of supporting clinical materials²² aim to improve primary care adoption of fall risk screening and intervention practices.^23,24 The epidemic of falls must compel all PCPs, not just those practicing geriatrics, to make discussing and addressing fall risk and falls a priority.

Methods

Setting

This project took place as part of a regional primary care effort in Oregon. Providence Health & Services-Oregon is part of a multi-state integrated health care system in the western United States whose PCPs serve more than 80,000 patients aged 65 years and older per year; these patients comprise 38% of the system’s office visits each year. Regionally, there are 47 family and internal medicine clinics employing roughly 290 providers (physicians, NPs, and physician assistants). The organization has only 4 PCPs trained in geriatrics and does not offer any geriatric clinical consultation services. Six PCPs from different clinics, representing both rural and urban settings, are chosen to participate in the geriatric mini-fellowship each year.

This project was conducted as a quality improvement initiative within the organization and did not constitute human subjects research. It was not conducted under the oversight of the Institutional Review Board.

Intervention

The mini-fellowship was taught in 4 1-week blocks between April and October 2018, with a curriculum designed to be interactive and practical. The faculty was intentionally interdisciplinary to teach and model team-based practice. Each week participants were excused from their clinical practice. Approximately 160 hours of continuing medical education credits were awarded for the full mini-fellowship. As part of each weekly session, a performance improvement project (PIP) focused on that week’s topic (1 of the 4Ms) was developed by the fellow and their team members to incorporate the mini-fellowship learnings into their clinic workflows. Fellows also had 2 hours per week of dedicated administration time for a year, outside the fellowship, to work on their PIP and 4M practice changes within their clinic.

Provider Education

The week for mobility training comprised 4 daylong sessions. The first 2 days were spent learning about the epidemiology of falls; risk factors for falling; how to conduct a thorough history and assessment of fall risk; and how to create a prioritized Fall Risk Management Plan (FRMP) to decrease a patient’s individual fall risk through tailored interventions. The FRMP was adapted from the CDC STEADI toolkit.¹³ Core faculty were 2 geriatric-trained providers (NP and physician) and a physical therapist (PT) specializing in fall prevention.

On the third day, fellows took part in a simulated fall risk clinic, in which older adults volunteered to be patient partners, providing an opportunity to apply learnings from days 1 and 2. The clinic included the fellow observing a PT complete a mobility assessment and a pharmacist conduct a high-risk medication review. The fellow synthesized the findings of the mobility assessment and medication review, as well as their own history and assessment, to create a summary of fall risk recommendations to discuss with their volunteer patient partner. The fellows were observed and evaluated in their skills by their patient partner, course faculty, and another fellow. The patient partners, and their assigned fellow, also participated in a 45-minute fall risk presentation, led by a nurse.

On the fourth day, the fellows were joined by select clinic partners, including nurses, pharmacists, and/or medical assistants. The session included discussions among each fellow’s clinical team regarding the current state of fall risk efforts at their clinic, an analysis of barriers, and identification of opportunities to improve workflows and screening rates. Each fellow took with them an action plan tailored to their clinic to improve fall risk management practices, starting with the fellow’s own practice.

Fall Risk Management Plan

The educational sessions introduced the fellows to the FRMP. The FRMP, adapted from the STEADI toolkit, includes a process for fall risk screening (Figure 1) and stratifying a patient’s risk based on their STEADI score in order to promote 3 priority assessments (gait evaluation with PT referral if appropriate; orthostatic blood pressure; and high-risk medication review; Figure 2). Initial actions based on these priority assessments were followed over time, with additional fall risk interventions added as clinically indicated.²⁵ The FRMP is intended to be used during routine office visits, Medicare annual wellness visits, or office visits focused on fall risk or related medical disorders (ie, fall risk visits.)

Providers and their teams were encouraged to spread out fall-related conversations with their patients over multiple visits, since many patients have multiple fall risk factors at play, in addition to other chronic medical issues, and since many interventions often require behavior changes on the part of the patient. Providers also had access to fall-related electronic health record (EHR) templates as well as a comprehensive, internal fall risk management website that included assessment tools, evidence-based resources, and patient handouts.

Assessment and Measurements

We assessed provider knowledge and comfort in their fall risk evaluation and management skills before and after the educational intervention using an 11-item multiple-choice questionnaire and a 4-item confidence questionnaire. The confidence questions used a 7-point Likert scale, with 0 indicating “no confidence” and 7 indicating ”lots of confidence.” The questions were administered via a paper survey. Qualitative comments were derived from evaluations completed at the end of the week.

The fellows’ practice of fall risk screening and management was studied from May 2018, at the completion of Mobility week, to May 2019 for the post-intervention period. A 1-year timeframe before May 2018 was used as the pre-intervention period. Eligible visit types, during which we assumed fall risk was discussed, were any office visits for patients 65+ completed by the patients’ PCPs that used fall risk as a reason for the visit or had a fall-related diagnosis code. Fall risk visits performed by other clinic providers were not counted.

Of those patients who had fall risk screenings completed and were determined to be high risk (STEADI score ≥ 4), data were analyzed to determine whether these patients had any fall-related follow-up visits to their PCP within 60 days of the STEADI screening. For these high-risk patients, data were studied to understand whether orthostatic blood pressure measurements were performed (as documented in a flowsheet) and whether a PT referral was placed. These data were compared with those from providers who practiced in clinics within the same system but who did not participate in the mini-fellowship. Data were obtained from the organization’s EHR. Additional data were measured to evaluate patterns of deprescribing of select high-risk medications, but these data are not included in this analysis.

Analysis

A paired-samples t test was used to measure changes in provider confidence levels. Data were aggregated across fellows, resulting in a mean. A chi-square test of independence was performed to examine the relationship between rates of FRMP adoption by select provider groups. Analysis included a pre- and post-intervention assessment of the fellows’ adoption of FRMP practices, as well as a comparison between the fellows’ practice patterns and those of a control group of PCPs in the organization’s other clinics who did not participate in the mini-fellowship (nontrained control group). Excluded from the control group were providers from the same clinic as the fellows; providers in clinics with a geriatric-trained provider on staff; and clinics outside of the Portland metro and Medford service areas. We used an alpha level of 0.05 for all statistical tests.

Data from 5 providers were included in the analysis of the FRMP adoption. The sixth provider changed practice settings from the clinic to the ED after completing the fellowship; her patient data were not included in the FRMP part of the analysis. EHR data included data on all visits of patients 65+, as well as data for just those 65+ patients who had been identified as being at high risk to fall based on a STEADI score of 4 or higher.

Results

Provider Questionnaire

All 6 providers responded to the pre-intervention and post-intervention tests. For the knowledge questions, fellows, as a composite, correctly answered 57% of the questions before the intervention and 79% after the intervention. Provider confidence level in delivering fall risk care was measured prior to the training (mean, 4.12 [SD, 0.62]) and at the end of the training (mean, 6.47 [SD, 0.45]), demonstrating a significant increase in confidence (t (5) = –10.46, P < 0.001).

Qualitative Comments

Providers also had the opportunity to provide comments on their experience during the Mobility week and at the end of 1 year. In general, the simulated interdisciplinary fall risk clinic was highly rated (“the highlight of the week”) as a practical strategy to embed learning principles. One fellow commented, “Putting the learning into practice helps solidify it in my brain.” Fellows also appreciated the opportunity to learn and meet with their clinic colleagues to begin work on a fall-risk focused PIP and to “have a framework for what to do for people who screen positive [for fall risk].”

FRMP Adoption

A comparison of the care the fellows provided to their patients 65+ in the 12 months pre- and post-training shows the fellows demonstrated significant changes in practice patterns. The fellows were 1.7 times more likely to screen for fall risk; 3.6 times more likely to discuss fall risk; and 5.8 times more likely to check orthostatic blood pressure than prior to the mini-fellowship (Table 1).

The control providers also demonstrated significant increases in fall risk screening and discussion of fall risk between the pre- and post-intervention periods; however, the relative risk (RR) was between 1.10 and 1.13 for this group. For the control group, checking orthostatic blood pressure did not significantly change. In the 12 months after training (Table 2), the fellows were 4.2 times more likely to discuss fall risk and almost 5 times more likely to check orthostatic blood pressure than their nontrained peers for all of their patients 65+, regardless of their risk to fall.

As shown in Table 3, for those patients determined to be at high risk of falling (STEADI score ≥ 4), fellows showed statistically significant increases in fall risk visits (RR, 3.02) and assessment of orthostatic blood pressure (RR, 10.68) before and after the mini-fellowship. The control providers did not show any changes in practice patterns between the pre- and post-period among patients at high risk to fall.

Neither the fellows nor the control group showed changes in patterns of referral to PT. In comparing the 2 groups in the 12 months after training (Table 4), for their patients at risk of falling, the fellows were 4 times more likely to complete fall risk visits and over 6 times more likely to assess orthostatic blood pressure than their nontrained peers. Subgroup analysis of the 75+ population revealed similar trends and significance, but these results are not included here.

Discussion

This study aimed to improve not only providers’ knowledge and confidence in caring for older adults at increased risk to fall, but also their clinical practice in assessing and managing fall risk. In addition to improved knowledge and confidence, we found that the fellows increased their discussion of fall risk (through fall risk visits) and their assessment of orthostatic blood pressure for all of their patients, not just for those identified at increased risk to fall. This improvement held true for the fellows themselves before and after the intervention, but also as compared to their nontrained peers. These practice improvements for all of their 65+ patients, not just those identified as being at high risk to fall, are especially important, since studies indicate that early screening and intervention can help identify people at risk and prevent future falls.¹⁵

We were surprised that there were no significant differences in PT referrals made by the trained fellows, but this finding may have been confounded by the fact that the data included all PT referrals, regardless of diagnosis, not just those referrals that were fall-related. Furthermore, our baseline PT referral rates, at 39% for the intervention group and 42% for the control group, are higher than national data when looking at rehabilitation use by older adults.²⁶

In comparison to a study evaluating the occurrence of fall risk–related clinical practice in primary care before any fall-related educational intervention, orthostatics were checked less frequently in our study (10% versus 30%) and there were fewer PT referrals (42%–44% versus 53%).²⁷ However, the Phelan study took place in patients who had actually had a fall, rather than just having a higher risk for a fall, and was based on detailed chart review. Other studies^23,24 found higher rates of fall risk interventions, but did not break out PT referrals specifically.

In terms of the educational intervention itself, most studies of geriatric education interventions have measured changes in knowledge, confidence, or self-efficacy as they relate to geriatric competence,^28-30 and do not measure practice change as an outcome outside of intent to change or self-reported practice change.^31,32 In general, practice change or longer-term health care–related outcomes have not been studied. Additionally, a range of dosages of educational interventions has been studied, from 1-hour lunchtime presentations^23,32 to half-day²⁹ or several half-day workshops,²⁸ up to 160 hours over 10 months³⁰ or 5 weekends over 6 months.³¹ The duration of our entire intervention at 160 hours over 6 months would be considered on the upper end of dosing relative to these studies, with our Mobility week intervention comprising 32 hours during 1 week. In the Warshaw study, despite 107 1-hour sessions being taught to over 60 physicians in 16 practices over 4 years, only 2 practices ultimately initiated any practice change projects.³² We believe that only curricula that embed practice change skills and opportunities, at a significant enough dose, can actually impact practice change in a sustainable manner.

Knowledge and skill acquisition among individual providers does not take place to a sufficient degree in the current health care arena, which is focused on productivity and short visit times. Consistent with other studies, we included interdisciplinary members of the primary care team for part of the mini-fellowship, although other studies used models that train across disciplines for the entirety of the learning experience.^28-30,33 Our educational model was strengthened by including other professionals to provide some of the education and model the ideal geriatric team, including PT, occupational therapy, and pharmacy, for the week on mobility.

Most studies exploring interventions through geriatric educational initiatives are conducted within academic institutions, with a primary focus on physician faculty and, by extension, their teaching of residents and others.^34,35 We believe our integrated model, which is steeped in community-based primary care practices like Lam’s,³¹ offers the greatest outreach to large community-based care systems and their patients. Training providers to work with their teams to change their own practices first gives skills and expertise that help further establish them as geriatric champions within their practices, laying the groundwork for more widespread practice change at their clinics.

Limitations

In addition to the limitations described above relating to the capture of PT referrals, other limitations included the relatively short time period for follow-up data as well as the small size of the intervention group. However, we found value in the instructional depth that the small group size allowed.

While the nontrained providers did show some improvement during the same period, we believe the relative risk was not clinically significant. We suspect that the larger health system efforts to standardize screening of patients 65+ across all clinics as a core quality metric confounded these results. The data analysis also included only fall-related patient visits that occurred with a provider who was that patient’s PCP, which could have missed visits done by other PCP colleagues, RNs, or pharmacists in the same clinic, thus undercounting the true number of fall-related visits. Furthermore, counting of fall-related interventions relied upon providers documenting consistently in the EHR, which could also lead to under-represention of fall risk clinical efforts.

The data presented, while encouraging, do not reflect clinic-wide practice change patterns and are considered only proximate outcomes rather than more long-term or cost-related outcomes, as would be captured by fall-related utilization measures like emergency room visits and hospitalizations. We expect to evaluate the broader impact and these value-based outcomes in the future. All providers and teams were from the same health care system, which may not allow our results to transfer to other organizations or regions of clinical practice.

Summary

This study demonstrates that an intensive mini-fellowship model of geriatrics training improved both knowledge and confidence in the realm of fall risk assessment and intervention among PCPs who had not been formally trained in geriatrics. More importantly, the training improved the fall-related care of their patients at increased risk to fall, but also of all of their older patients, with improvements in care measured up to a year after the mini-fellowship. Although this article only describes the work done as part of the Mobility aim of the 4M AFHS model, we believe the entire mini-fellowship curriculum offers the opportunity to “geriatricize” clinicians and their teams in learning geriatric principles and skills that they can translate into their practice in a sustainable way, as Tinetti encourages.⁸ Future study to evaluate other process outcomes more precisely, such as PT, as well as cost- and value-based outcomes, and the influence of trained providers on their clinic partners, will further establish the value proposition of targeted, disseminated, intensive geriatrics training of primary care clinicians as a strategy of age-friendly health systems as they work to improve the care of their older adults.

Acknowledgment: We are grateful for the dedication and hard work of the 2018 Geriatric Mini-Fellowship fellows at Providence Health & Services-Oregon who made this article possible. Thanks to Drs. Stephanie Cha, Emily Puukka-Clark, Laurie Dutkiewicz, Cara Ellis, Deb Frost, Jordan Roth, and Subhechchha Shah for promoting the AFHS work within their Providence Medical Group clinics and to PMG leadership and the fellows’ clinical teams for supporting the fellows, the AFHS work, and their older patients.

Corresponding author: Colleen M. Casey, PhD, ANP-BC, Providence Health & Services, Senior Health Program, 4400 NE Halsey, 5th Floor, Portland, OR 97213; [email protected].

Financial disclosures: None.

From the Senior Health Program, Providence Health & Services, Oregon, Portland, OR.

Abstract

Background: Approximately 51 million adults in the United States are 65 years of age or older, yet few geriatric-trained primary care providers (PCP) serve this population. The Age-Friendly Health System framework, consisting of evidence-based 4M care (Mobility, Medication, Mentation, and what Matters), encourages all PCPs to assess mobility in older adults.

Objective: To improve PCP knowledge, confidence, and clinical practice in assessing and managing fall risk.

Methods: A 1-week educational session focusing on mobility (part of a 4-week Geriatric Mini-Fellowship) for 6 selected PCPs from a large health care system was conducted to increase knowledge and ability to address fall risk in older adults. The week included learning and practicing a Fall Risk Management Plan (FRMP) algorithm, including planning for their own practice changes. Pre- and post-test surveys assessed changes in knowledge and confidence. Patient data were compared 12 months before and after training to evaluate PCP adoption of FRMP components.

Results: The training increased provider knowledge and confidence. The trained PCPs were 1.7 times more likely to screen for fall risk; 3.6 times more likely to discuss fall risk; and 5.8 times more likely to assess orthostatic blood pressure in their 65+ patients after the mini-fellowship. In high-risk patients, they were 4.1 times more likely to discuss fall risk and 6.3 times more likely to assess orthostatic blood pressure than their nontrained peers. Changes in physical therapy referral rates were not observed.

Conclusions: In-depth, skills-based geriatric educational sessions improved PCPs’ knowledge and confidence and also improved their fall risk management practices for their older patients.

Keywords: geriatrics; guidelines; Age-Friendly Health System; 4M; workforce training; practice change; fellowship.

The US population is aging rapidly. People aged 85 years and older are the largest-growing segment of the US population, and this segment is expected to increase by 123% by 2040.¹ Caregiving needs increase with age as older adults develop more chronic conditions, such as hypertension, heart disease, arthritis, and dementia. However, even with increasing morbidity and dependence, a majority of older adults still live in the community rather than in institutional settings.² These older adults seek medical care more frequently than younger people, with about 22% of patients 75 years and older having 10 or more health care visits in the previous 12 months. By 2040, nearly a quarter of the US population is expected to be 65 or older, with many of these older adults seeking regular primary care from providers who do not have formal training in the care of a population with multiple complex, chronic health conditions and increased caregiving needs.¹

Despite this growing demand for health care professionals trained in the care of older adults, access to these types of clinicians is limited. In 2018, there were roughly 7000 certified geriatricians, with only 3600 of them practicing full-time.^3,4 Similarly, of 290,000 certified nurse practitioners (NPs), about 9% of them have geriatric certification.⁵ Geriatricians, medical doctors trained in the care of older adults, and geriatric-trained NPs are part of a cadre of a geriatric-trained workforce that provides unique expertise in caring for older adults with chronic and advanced illness. They know how to manage multiple, complex geriatric syndromes like falls, dementia, and polypharmacy; understand and maximize team-based care; and focus on caring for an older person with a goal-centered versus a disease-centered approach.⁶

Broadly, geriatric care includes a spectrum of adults, from those who are aging healthfully to those who are the frailest. Research has suggested that approximately 30% of older adults need care by a geriatric-trained clinician, with the oldest and frailest patients needing more clinician time for assessment and treatment, care coordination, and coaching of caregivers.⁷ With this assumption in mind, it is projected that by 2025, there will be a national shortage of 26,980 geriatricians, with the western United States disproportionately affected by this shortage.⁴Rather than lamenting this shortage, Tinetti recommends a new path forward: “Our mission should not be to train enough geriatricians to provide direct care, but rather to ensure that every clinician caring for older adults is competent in geriatric principles and practices.”⁸ Sometimes called ”geriatricizing,” the idea is to use existing geriatric providers as a small elite training force to infuse geriatric principles and skills across their colleagues in primary care and other disciplines.^8,9 Efforts of the American Geriatrics Society (AGS), with support from the John A. Hartford Foundation (JAHF), have been successful in developing geriatric training across multiple specialties, including surgery, orthopedics, and emergency medicine (www.americangeriatrics.org/programs/geriatrics-specialists-initiative).

The Age-Friendly Health System and 4M Model

To help augment this idea of equipping health care systems and their clinicians with more readily available geriatric knowledge, skills, and tools, the JAHF, along with the Institute for Healthcare Improvement (IHI), created the Age-Friendly Health System (AFHS) paradigm in 2015.¹⁰ Using the 4M model, the AFHS initiative established a set of evidence-based geriatric priorities and interventions meant to improve the care of older adults, reduce harm and duplication, and provide a framework for engaging leadership, clinical teams, and operational systems across inpatient and ambulatory settings.¹¹ Mobility, including fall risk screening and intervention, is 1 of the 4M foundational elements of the Age-Friendly model. In addition to Mobility, the 4M model also includes 3 other key geriatric domains: Mentation (dementia, depression, and delirium), Medication (high-risk medications, polypharmacy, and deprescribing), and What Matters (goals of care conversations and understanding quality of life for older patients).¹¹ The 4M initiative encourages adoption of a geriatric lens that looks across chronic conditions and accounts for the interplay among geriatric syndromes, such as falls, cognitive impairment, and frailty, in order to provide care better tailored to what the patient needs and desires.¹² IHI and JAHF have targeted the adoption of the 4M model by 20% of US health care systems by 2020.¹¹

Mini-Fellowship and Mobility Week

To bolster geriatric skills among community-based primary care providers (PCPs), we initiated a Geriatric Mini-Fellowship, a 4-week condensed curriculum taught over 6 months. Each week focuses on 1 of the age-friendly 4Ms, with the goal of increasing the knowledge, self-efficacy, skills, and competencies of the participating PCPs (called “fellow” hereafter) and at the same time, equipping each to become a champion of geriatric practice. This article focuses on the Mobility week, the second week of the mini-fellowship, and the effect of the week on the fellows’ practice changes.

To construct the Mobility week’s curriculum with a focus on the ambulatory setting, we relied upon national evidence-based work in fall risk management. The Centers for Disease Control and Prevention (CDC) has made fall risk screening and management in primary care a high priority. Using the clinical practice guidelines for managing fall risk developed by the American and British Geriatrics Societies (AGS/BGS), the CDC developed the Stopping Elderly Accidents, Deaths, and Injuries (STEADI) toolkit.¹³ Foundational to the toolkit is the validated 12-item Stay Independent falls screening questionnaire (STEADI questionnaire).¹⁴ Patients who score 4 or higher (out of a total score of 14) on the questionnaire are considered at increased risk of falling. The CDC has developed a clinical algorithm that guides clinical teams through screening and assessment to help identify appropriate interventions to target specific risk factors. Research has clearly established that a multifactorial approach to fall risk intervention can be successful in reducing fall risk by as much as 25%.^15-17

The significant morbidity and mortality caused by falls make training nongeriatrician clinicians on how to better address fall risk imperative. More than 25% of older adults fall each year.¹⁸ These falls contribute to rising rates of fall-related deaths,¹⁹ emergency department (ED) visits,²⁰ and hospital readmissions.²¹ Initiatives like the AFHS focus on mobility and the CDC’s development of supporting clinical materials²² aim to improve primary care adoption of fall risk screening and intervention practices.^23,24 The epidemic of falls must compel all PCPs, not just those practicing geriatrics, to make discussing and addressing fall risk and falls a priority.

Methods

Setting

This project took place as part of a regional primary care effort in Oregon. Providence Health & Services-Oregon is part of a multi-state integrated health care system in the western United States whose PCPs serve more than 80,000 patients aged 65 years and older per year; these patients comprise 38% of the system’s office visits each year. Regionally, there are 47 family and internal medicine clinics employing roughly 290 providers (physicians, NPs, and physician assistants). The organization has only 4 PCPs trained in geriatrics and does not offer any geriatric clinical consultation services. Six PCPs from different clinics, representing both rural and urban settings, are chosen to participate in the geriatric mini-fellowship each year.

This project was conducted as a quality improvement initiative within the organization and did not constitute human subjects research. It was not conducted under the oversight of the Institutional Review Board.

Intervention

The mini-fellowship was taught in 4 1-week blocks between April and October 2018, with a curriculum designed to be interactive and practical. The faculty was intentionally interdisciplinary to teach and model team-based practice. Each week participants were excused from their clinical practice. Approximately 160 hours of continuing medical education credits were awarded for the full mini-fellowship. As part of each weekly session, a performance improvement project (PIP) focused on that week’s topic (1 of the 4Ms) was developed by the fellow and their team members to incorporate the mini-fellowship learnings into their clinic workflows. Fellows also had 2 hours per week of dedicated administration time for a year, outside the fellowship, to work on their PIP and 4M practice changes within their clinic.

Provider Education

The week for mobility training comprised 4 daylong sessions. The first 2 days were spent learning about the epidemiology of falls; risk factors for falling; how to conduct a thorough history and assessment of fall risk; and how to create a prioritized Fall Risk Management Plan (FRMP) to decrease a patient’s individual fall risk through tailored interventions. The FRMP was adapted from the CDC STEADI toolkit.¹³ Core faculty were 2 geriatric-trained providers (NP and physician) and a physical therapist (PT) specializing in fall prevention.

On the third day, fellows took part in a simulated fall risk clinic, in which older adults volunteered to be patient partners, providing an opportunity to apply learnings from days 1 and 2. The clinic included the fellow observing a PT complete a mobility assessment and a pharmacist conduct a high-risk medication review. The fellow synthesized the findings of the mobility assessment and medication review, as well as their own history and assessment, to create a summary of fall risk recommendations to discuss with their volunteer patient partner. The fellows were observed and evaluated in their skills by their patient partner, course faculty, and another fellow. The patient partners, and their assigned fellow, also participated in a 45-minute fall risk presentation, led by a nurse.

On the fourth day, the fellows were joined by select clinic partners, including nurses, pharmacists, and/or medical assistants. The session included discussions among each fellow’s clinical team regarding the current state of fall risk efforts at their clinic, an analysis of barriers, and identification of opportunities to improve workflows and screening rates. Each fellow took with them an action plan tailored to their clinic to improve fall risk management practices, starting with the fellow’s own practice.

Fall Risk Management Plan

The educational sessions introduced the fellows to the FRMP. The FRMP, adapted from the STEADI toolkit, includes a process for fall risk screening (Figure 1) and stratifying a patient’s risk based on their STEADI score in order to promote 3 priority assessments (gait evaluation with PT referral if appropriate; orthostatic blood pressure; and high-risk medication review; Figure 2). Initial actions based on these priority assessments were followed over time, with additional fall risk interventions added as clinically indicated.²⁵ The FRMP is intended to be used during routine office visits, Medicare annual wellness visits, or office visits focused on fall risk or related medical disorders (ie, fall risk visits.)

Providers and their teams were encouraged to spread out fall-related conversations with their patients over multiple visits, since many patients have multiple fall risk factors at play, in addition to other chronic medical issues, and since many interventions often require behavior changes on the part of the patient. Providers also had access to fall-related electronic health record (EHR) templates as well as a comprehensive, internal fall risk management website that included assessment tools, evidence-based resources, and patient handouts.

Assessment and Measurements

We assessed provider knowledge and comfort in their fall risk evaluation and management skills before and after the educational intervention using an 11-item multiple-choice questionnaire and a 4-item confidence questionnaire. The confidence questions used a 7-point Likert scale, with 0 indicating “no confidence” and 7 indicating ”lots of confidence.” The questions were administered via a paper survey. Qualitative comments were derived from evaluations completed at the end of the week.

The fellows’ practice of fall risk screening and management was studied from May 2018, at the completion of Mobility week, to May 2019 for the post-intervention period. A 1-year timeframe before May 2018 was used as the pre-intervention period. Eligible visit types, during which we assumed fall risk was discussed, were any office visits for patients 65+ completed by the patients’ PCPs that used fall risk as a reason for the visit or had a fall-related diagnosis code. Fall risk visits performed by other clinic providers were not counted.

Of those patients who had fall risk screenings completed and were determined to be high risk (STEADI score ≥ 4), data were analyzed to determine whether these patients had any fall-related follow-up visits to their PCP within 60 days of the STEADI screening. For these high-risk patients, data were studied to understand whether orthostatic blood pressure measurements were performed (as documented in a flowsheet) and whether a PT referral was placed. These data were compared with those from providers who practiced in clinics within the same system but who did not participate in the mini-fellowship. Data were obtained from the organization’s EHR. Additional data were measured to evaluate patterns of deprescribing of select high-risk medications, but these data are not included in this analysis.

Analysis

A paired-samples t test was used to measure changes in provider confidence levels. Data were aggregated across fellows, resulting in a mean. A chi-square test of independence was performed to examine the relationship between rates of FRMP adoption by select provider groups. Analysis included a pre- and post-intervention assessment of the fellows’ adoption of FRMP practices, as well as a comparison between the fellows’ practice patterns and those of a control group of PCPs in the organization’s other clinics who did not participate in the mini-fellowship (nontrained control group). Excluded from the control group were providers from the same clinic as the fellows; providers in clinics with a geriatric-trained provider on staff; and clinics outside of the Portland metro and Medford service areas. We used an alpha level of 0.05 for all statistical tests.

Data from 5 providers were included in the analysis of the FRMP adoption. The sixth provider changed practice settings from the clinic to the ED after completing the fellowship; her patient data were not included in the FRMP part of the analysis. EHR data included data on all visits of patients 65+, as well as data for just those 65+ patients who had been identified as being at high risk to fall based on a STEADI score of 4 or higher.

Results

Provider Questionnaire

All 6 providers responded to the pre-intervention and post-intervention tests. For the knowledge questions, fellows, as a composite, correctly answered 57% of the questions before the intervention and 79% after the intervention. Provider confidence level in delivering fall risk care was measured prior to the training (mean, 4.12 [SD, 0.62]) and at the end of the training (mean, 6.47 [SD, 0.45]), demonstrating a significant increase in confidence (t (5) = –10.46, P < 0.001).

Qualitative Comments

Providers also had the opportunity to provide comments on their experience during the Mobility week and at the end of 1 year. In general, the simulated interdisciplinary fall risk clinic was highly rated (“the highlight of the week”) as a practical strategy to embed learning principles. One fellow commented, “Putting the learning into practice helps solidify it in my brain.” Fellows also appreciated the opportunity to learn and meet with their clinic colleagues to begin work on a fall-risk focused PIP and to “have a framework for what to do for people who screen positive [for fall risk].”

FRMP Adoption

A comparison of the care the fellows provided to their patients 65+ in the 12 months pre- and post-training shows the fellows demonstrated significant changes in practice patterns. The fellows were 1.7 times more likely to screen for fall risk; 3.6 times more likely to discuss fall risk; and 5.8 times more likely to check orthostatic blood pressure than prior to the mini-fellowship (Table 1).

The control providers also demonstrated significant increases in fall risk screening and discussion of fall risk between the pre- and post-intervention periods; however, the relative risk (RR) was between 1.10 and 1.13 for this group. For the control group, checking orthostatic blood pressure did not significantly change. In the 12 months after training (Table 2), the fellows were 4.2 times more likely to discuss fall risk and almost 5 times more likely to check orthostatic blood pressure than their nontrained peers for all of their patients 65+, regardless of their risk to fall.

As shown in Table 3, for those patients determined to be at high risk of falling (STEADI score ≥ 4), fellows showed statistically significant increases in fall risk visits (RR, 3.02) and assessment of orthostatic blood pressure (RR, 10.68) before and after the mini-fellowship. The control providers did not show any changes in practice patterns between the pre- and post-period among patients at high risk to fall.

Neither the fellows nor the control group showed changes in patterns of referral to PT. In comparing the 2 groups in the 12 months after training (Table 4), for their patients at risk of falling, the fellows were 4 times more likely to complete fall risk visits and over 6 times more likely to assess orthostatic blood pressure than their nontrained peers. Subgroup analysis of the 75+ population revealed similar trends and significance, but these results are not included here.

Discussion

This study aimed to improve not only providers’ knowledge and confidence in caring for older adults at increased risk to fall, but also their clinical practice in assessing and managing fall risk. In addition to improved knowledge and confidence, we found that the fellows increased their discussion of fall risk (through fall risk visits) and their assessment of orthostatic blood pressure for all of their patients, not just for those identified at increased risk to fall. This improvement held true for the fellows themselves before and after the intervention, but also as compared to their nontrained peers. These practice improvements for all of their 65+ patients, not just those identified as being at high risk to fall, are especially important, since studies indicate that early screening and intervention can help identify people at risk and prevent future falls.¹⁵

We were surprised that there were no significant differences in PT referrals made by the trained fellows, but this finding may have been confounded by the fact that the data included all PT referrals, regardless of diagnosis, not just those referrals that were fall-related. Furthermore, our baseline PT referral rates, at 39% for the intervention group and 42% for the control group, are higher than national data when looking at rehabilitation use by older adults.²⁶

In comparison to a study evaluating the occurrence of fall risk–related clinical practice in primary care before any fall-related educational intervention, orthostatics were checked less frequently in our study (10% versus 30%) and there were fewer PT referrals (42%–44% versus 53%).²⁷ However, the Phelan study took place in patients who had actually had a fall, rather than just having a higher risk for a fall, and was based on detailed chart review. Other studies^23,24 found higher rates of fall risk interventions, but did not break out PT referrals specifically.

In terms of the educational intervention itself, most studies of geriatric education interventions have measured changes in knowledge, confidence, or self-efficacy as they relate to geriatric competence,^28-30 and do not measure practice change as an outcome outside of intent to change or self-reported practice change.^31,32 In general, practice change or longer-term health care–related outcomes have not been studied. Additionally, a range of dosages of educational interventions has been studied, from 1-hour lunchtime presentations^23,32 to half-day²⁹ or several half-day workshops,²⁸ up to 160 hours over 10 months³⁰ or 5 weekends over 6 months.³¹ The duration of our entire intervention at 160 hours over 6 months would be considered on the upper end of dosing relative to these studies, with our Mobility week intervention comprising 32 hours during 1 week. In the Warshaw study, despite 107 1-hour sessions being taught to over 60 physicians in 16 practices over 4 years, only 2 practices ultimately initiated any practice change projects.³² We believe that only curricula that embed practice change skills and opportunities, at a significant enough dose, can actually impact practice change in a sustainable manner.

Knowledge and skill acquisition among individual providers does not take place to a sufficient degree in the current health care arena, which is focused on productivity and short visit times. Consistent with other studies, we included interdisciplinary members of the primary care team for part of the mini-fellowship, although other studies used models that train across disciplines for the entirety of the learning experience.^28-30,33 Our educational model was strengthened by including other professionals to provide some of the education and model the ideal geriatric team, including PT, occupational therapy, and pharmacy, for the week on mobility.

Most studies exploring interventions through geriatric educational initiatives are conducted within academic institutions, with a primary focus on physician faculty and, by extension, their teaching of residents and others.^34,35 We believe our integrated model, which is steeped in community-based primary care practices like Lam’s,³¹ offers the greatest outreach to large community-based care systems and their patients. Training providers to work with their teams to change their own practices first gives skills and expertise that help further establish them as geriatric champions within their practices, laying the groundwork for more widespread practice change at their clinics.

Limitations

In addition to the limitations described above relating to the capture of PT referrals, other limitations included the relatively short time period for follow-up data as well as the small size of the intervention group. However, we found value in the instructional depth that the small group size allowed.

While the nontrained providers did show some improvement during the same period, we believe the relative risk was not clinically significant. We suspect that the larger health system efforts to standardize screening of patients 65+ across all clinics as a core quality metric confounded these results. The data analysis also included only fall-related patient visits that occurred with a provider who was that patient’s PCP, which could have missed visits done by other PCP colleagues, RNs, or pharmacists in the same clinic, thus undercounting the true number of fall-related visits. Furthermore, counting of fall-related interventions relied upon providers documenting consistently in the EHR, which could also lead to under-represention of fall risk clinical efforts.

The data presented, while encouraging, do not reflect clinic-wide practice change patterns and are considered only proximate outcomes rather than more long-term or cost-related outcomes, as would be captured by fall-related utilization measures like emergency room visits and hospitalizations. We expect to evaluate the broader impact and these value-based outcomes in the future. All providers and teams were from the same health care system, which may not allow our results to transfer to other organizations or regions of clinical practice.

Summary

This study demonstrates that an intensive mini-fellowship model of geriatrics training improved both knowledge and confidence in the realm of fall risk assessment and intervention among PCPs who had not been formally trained in geriatrics. More importantly, the training improved the fall-related care of their patients at increased risk to fall, but also of all of their older patients, with improvements in care measured up to a year after the mini-fellowship. Although this article only describes the work done as part of the Mobility aim of the 4M AFHS model, we believe the entire mini-fellowship curriculum offers the opportunity to “geriatricize” clinicians and their teams in learning geriatric principles and skills that they can translate into their practice in a sustainable way, as Tinetti encourages.⁸ Future study to evaluate other process outcomes more precisely, such as PT, as well as cost- and value-based outcomes, and the influence of trained providers on their clinic partners, will further establish the value proposition of targeted, disseminated, intensive geriatrics training of primary care clinicians as a strategy of age-friendly health systems as they work to improve the care of their older adults.

Acknowledgment: We are grateful for the dedication and hard work of the 2018 Geriatric Mini-Fellowship fellows at Providence Health & Services-Oregon who made this article possible. Thanks to Drs. Stephanie Cha, Emily Puukka-Clark, Laurie Dutkiewicz, Cara Ellis, Deb Frost, Jordan Roth, and Subhechchha Shah for promoting the AFHS work within their Providence Medical Group clinics and to PMG leadership and the fellows’ clinical teams for supporting the fellows, the AFHS work, and their older patients.

Corresponding author: Colleen M. Casey, PhD, ANP-BC, Providence Health & Services, Senior Health Program, 4400 NE Halsey, 5th Floor, Portland, OR 97213; [email protected].

Financial disclosures: None.

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