Category: primary care

Place matters, teachers and learners #CCME18

mountain climber

We learn best in places that support our learning and our bio psycho socio spiritual development – from toddlers to elders, reports Jan Klimas from the Canadian Medical Education conference #CCME18.

Starting in Toronto, Justin Hsu and colleagues from University of Toronto described how they improved spaces for communities in teaching ambulatory care, or the so called Medical Education Teaching Clinics (METC). They plan to evaluate METC clinics via audit of referrals to the teaching clinic and the learner satisfaction survey.
Presentation title: Creating unique spaces to support community-based ambulatory care education: the E3 experience.
Presentation authors: Jerry Maniate, Elizabeth Wooster, Douglas Wooster, Justin Hsu

British Columbia quality matters

Jan Klimas’ team from University of British Columbia evaluated hospital as a place of learning about substance use disorders. Who learns most about addictions in hospitals? Using mixed-methods approach, this team showed that medical students get more out of a rotation in hospital than residents or senior learners. Especially in the areas of safe prescribing, screening and withdrawal management. Why is that? Do residents know more or are they more resistant to new learning? For many medical students, hospital could be the first place where they see someone with addiction and that could be why they learn more in this setting.
Presentation title: Who learns most about addiction in the hospitals? A mixed methods study.
Presentation authors: Jan Klimas, Evan Wood, Walter Cullen, Will Small, Seonaid Nolan, Annabel Mead, Mark McLean, Christophe Fairgrieve, Keith Ahamad, Huiru Dong, Breanne Reel, Lauren Gorfinkel, Nadia Fairbairn

Derek Wilson and colleagues from the same university focused on the quality of health education learning environment (HELES study). HELES survey tool looked at relationship, personal development and program culture as the key parts of the learning environment at the faculty of medicine. For example, the evaluation asked whether the learners have developed a strong sense of community.
Presentation title: Evaluating the Quality of Health Professions Learning Environments: Validation of the Health Education Learning Environment Survey (HELES).
Presentation authors: Derek Wilson, Shayna Rusticus, Derek Wilson, Oscar Casiro, Kevin Eva, Lisa Hazlett, Chris Lovato

Calgary explores and experiences

Maureen Topps and collaborators from University of Calgary, Cumming School of Medicine, asked whether in addition to focusing on the deficiencies and gaps in education, whether we could research the successful activities related to professionalism. The postgraduate education is a key stage in training the next generation of competent and professional clinicians. Professionalism is hard to define and to define it may “limit it,” as Dr Barnhoorn writes in the Academic Medicine journal (2006, Vol. 91, No. 9). But how does the place of learning make for more professional doctors? Slowing down and taking time to plan interactions appears to foster professionalism among other factors such as communication training.
Presentation title: Contexts and Experiences of Postgraduate Residents that support successfully meeting professionalism challenges.
Presentation authors: Janet de Groot, Maureen Topps, Aliya Kassam, Maureen Topps

Nicole Delaloye and colleagues from the same university presented results from her Masters research of the MSc/MD program. Clinicians should be both polite and respective, but not overly submissive. Why do we follow orders? Resuscitation requires wise action, not passive deference. What happens when learners hold back too much and how does the place of learning impact submissiveness? Mechanisms that underly submission in the moment of revival include learner’s mental state, what was going on inside and outside the room, team and motivation.
Presentation title: An Exploration of Deference Behaviours Exhibited within the Paediatric Resuscitation Environment and the Educational Implications.
Presentation authors: Nicole Delaloye, Elaine Gilfoyle, Rachel Ellaway, Aliya Kassam, Elizabeth Oddone Paolucci

In summary, the best learning places not only support our learning, but also challenge us to learn knew knowledge, adopt the discipline’s values, overcome deference and become successful professionals in our own right.

The opinions and views in this article present the views of the author and not the named persons or the #CCME18 conference organisers.

Does alcohol use change after shift to Methadose?

alcohol drink, methadose
Do people drink more when they switch to Methadose? It is 10 times more concentrated than methadone –  proven treatment of opioid use disorder. We did not find more drinking after the switch. But others found changes in opioid use patterns coinciding with the change.

switch
We talked to 787 people receiving methadone for opioid use disorder in Vancouver, Canada.  Our new study followed them as they switched from methadone (1mg/mL) to Methadose (10mg/mL). We asked whether their drinking has changed after the switch – between 2013 and 2015. 16% said they drank too much at least once in the last six months. Those who drank too much were not more likely to do so after the shift to Methadose. The Substance Use& Misuse journal has published the study this week. 
Persons on methadone for opioid use disorder may report going through opioid withdrawal and increasing their illicit opioid use when switched to Methadose. We need to understand impacts of these changes on other forms of drug use. Careful and planned information about upcoming changes may help people cope with the potential risks better.

Conclusion

In sum, change is the law of life. Those who do not change do not survive in nature. For complex systems, such as health care, change management is the key to success. Healthy, happy and satisfied patients are healthcare’s success best proof. If they self-report negative experiences following methadone changes, their opinions should inform change management in order to build a better, patient-centered care. Their opinions, together with our findings, could help future formulary decisions in addiction treatment. Various methadone formulations may have little short-term impact on heavy alcohol use. Let’s evaluate the long-term impact.

Naloxone and Irish Primary Care Practitioners

We wanted to know what General Practitioners’ (GP) views and experiences of opioid addiction, overdose care and naloxone provision are. Naloxone is an antidote to opioid overdose, also known as Narcan.

How was the study done?
We sent 448 GPs an anonymous postal survey.
They all had students on placements from University College Dublin in Ireland.
Over 75% of GPs had patients who used illicit opiates, and 25% prescribed methadone to treat opioid use disorders.



What did the study find?
We found that two thirds of GPs were in favour of a project to increase naloxone availability in the community; almost one third would take part in such a scheme. Intranasal naloxone was much preferred to single, or multiple dose, intramuscular naloxone.  Few GPs objected to wider naloxone availability.
Irish primary care doctors are keen to distribute Naloxone in the community.
Why is the study important?
Every year, more people die in Ireland due to opioid overdoses than in car accidents.
Over 200 overdose deaths occur annually in Ireland.  Overdose prevention and management, including naloxone provision, should be a priority for healthcare services.   Naloxone is an effective treatment and is now being considered for wider lay use. This study showed that general practitioners commonly provide healthcare for patients with opiate use disorder and want more naloxone in this setting.

Reference:
Barry, T., Klimas, J., Tobin, H., Egan, M., Bury, G. (2017) Opiate Addiction and Overdose: Experiences, Attitudes and Appetite for Community Naloxone Provision. British Journal of General Practice. In press  http://bjgp.org/content/early/2017/02/27/bjgp17X689857/tab-article-info

Hospital teaching teams confront iatrogenic opioid addiction

What can hospital teams teach medical students about addiction to help curb the opioid overdose epidemic?

In a new article published by the Substance Abuse journal,  we report findings suggesting that the completion of an elective with a hospital-based Addiction Medicine Consult Team appeared to improve medical trainees’ knowledge which can help routinely establish clinical training teams elsewhere. 


We found that both emerging and established physicians appear to be responsive to this type of training.  The learner self-assessment can provide valuable feedback to the consultants, who can then focus more on the un-improved areas.

The study sample was drawn from medical students, residents and physicians who took part in a month-long rotation with a hospital-based addiction medicine consult team in Vancouver, Canada. Each year, approximately 60 learners go through the programme. Learners are asked to do a before and after self-assessment of their knowledge on addiction. The addiction rotation consisted of 4-12  weeks of full-time clinical training involving intake assessment, treatment planning, referrals to community agencies and starting people on evidence-based medications for substance use disorders. The learners take part in didactic lectures, bedside teaching, journal clubs and some prepare papers for submission to peer-reviewed journals. 

At the end of the learners reported increased knowledge in all but one of the areas of teaching focus, including opioid use disorders;  this increase was statistically significant. These preliminary, first-year results suggest that a structured clinical  training program could lead to an increased knowledge on addiction.

For more info read the full article “Impact of a Brief Addiction Medicine Training Experience on Knowledge Self-assessment among Medical Learners” at: to: http://www.tandfonline.com/doi/full/10.1080/08897077.2017.1296055

Two birds with one stone: physicians training in research

Combined training in addiction medicine and research is feasible and acceptable for physicians – a new study shows; however, there are important barriers to overcome and improved understanding of the experience of addiction physicians in the clinician-scientist track is required.

Addiction care is usually provided by unskilled lay-persons in most countries. The resulting care is inadequate, effective treatments are overlooked and millions of people suffer despite recent discovery of new treatments for substance use disorders. In rare instances when addiction care is provided by medical professionals, they are not adequately trained in caring for people with substance use disorders and, therefore, feel unprepared to provide such care.  Physician scientists are the bridge between science and practice. Despite large evidence-base upon which to base clinical practice, most health systems have not combined training of healthcare providers in addiction medicine and research. 
In recent years, new programmes have emerged to train the comprehensive addiction medicine professionals internationally.

We undertook a qualitative study to assess the experiences of 26 physicians who completed such a training programme in Vancouver, Canada. They included psychiatrists, internal medicine and family medicine physicians, faculty, mentors, medical students and residents. All received both addiction medicine and research training. Drawing on Kirkpatrick’s model of evaluating training programmes, we analysed the interviews thematically using qualitative data analysis software. We identified five themes relating to learning experience that were influential: (i) attitude, (ii) knowledge, (iii) skill, (iv) behaviour and (v) patient outcome. The presence of a supportive learning environment, flexibility in time lines, highly structured rotations, and clear guidance regarding development of research products facilitated clinician-scientist training.  Competing priorities, to include clinical and family responsibilities, hindered training.

Read more here: http://bmcmededuc.biomedcentral.com/articles/10.1186/s12909-017-0862-y
Klimas, J., McNeil, R., Ahamad, K., Mead, A., Rieb, L., Cullen, W., Wood, E., Small, W. (2017) Two birds with one stone: Experiences of Combining Clinical and Research Training in Addiction Medicine. BMC Medical Education, 17:22