Introduction: The need for better skills training related to addiction risk associated with pain treatment is understood (CASA, 2005;; Merrill, 2002; Lin, 2007). But data to guide such development so that it emphasizes the greatest need is limited. Materials and Methods: We interviewed six primary care providers about their concerns and challenges in prescribing opioids and treating pain and addiction as well as their needs and preferences regarding continuing medical education (CME) courses on pain and addiction.
Results: The PCPS greatest concern when prescribing opioids to patients was the potential for addiction. Their greatest challenges were: 1) diversion, 2) co-occurring psychiatric disorder, and 3) inability of non-opioid treatments to relieve pain. Some participants felt that additional training would help address these challenges. For treating pain in already-addicted patients, they requested information on: 1) discerning drug-seeking behavior due to addiction vs. under-treated pain, 2) identifying relapse into addiction, 3) urine drug testing, 4) informed consent and treatment agreements, 5) how to
take an addiction history, and 6) referral resources and clinical tools to help clinicians identify, interview, and manage addicted patients. Participants expressed the most interest in back pain, fibromyalgia, neuropathy, and osteoarthritis. Their greatest interest for practical skills training was in screening for addiction or interviewing pain patients.
Conclusions: PCPs identify a need for education on the risk of addiction in patients with pain. Meeting that need will require a comprehensive resource addressing multiple skills deficits and tools to help the provider find appropriate resources.
This research is funded by NIDA/NIH contract #HHSN271200800012C
1. CASA. Under the counter: The diversion and abuse of controlled prescription drugs in the U.S. The National Center on Addiction and Substance Abuse at Columbia University. 2005.
2. Lin JJ, Alfandre D, Moore C. Physician attitudes toward opioid prescribing for patients with persistent noncancer pain. Clinical Journal of Pain. 2007;23(9):799-803.
3. Merrill JO, Rhodes LA, Deyo RA, Marlatt A, Bradley KA. Mutual mistrust in the medical care of drug users. Journal of General Internal Medicine. 2002;17:327-333.
Idea: For medical students in the pre-clinical years, Standardized Patients (SPs) can help the learner integrate medical science knowledge into a clinical framework. A remote SP experience, where the encounter occurs via the Internet in comparison to traditional “face-to-face” encounters, could offer many advantages.
Why the Idea was Necessary: A pool of remote SPs could be potentially less expensive, and more available. Also, the remoteness may offer an opportunity for more variety in patients and the anonymity may offer other benefits. Although there is an abundance of experience with the utilization of SPs in a live context, the concept of utilizing remote SPs is novel. There are few standards to guide educators interested in utilizing SPs remotely.
What Needs to be Done: We seek to determine the parameters that would define a successful remote SP encounter. We seek to reach consensus regarding the implementation of a remote SP experience from leaders in medical education innovation.
Evaluation Plan: A modified Delphi approach will be used to gather feedback. After explaining the theory behind the “remote” SP encounter, we will then use iterative rounds of discussion to create the framework on which to build our “remote” SP experience. As an example, we will reach consensus on learner-patient interaction technology as
follows: Round 1 will present options for modes of delivery (chat, video, discussion boards, or other technology) and elicit further suggestions. Based on responses, we will ask participants to rate the importance of the mode of delivery in Round 2. Discussions will continue until a general consensus is reached on the optimal mode of delivery of the proposed remote SP experience. Additional consensus will be sought in terms of how to integrate remote SPs into other educational approaches (such as TBL), the value of being able to engage a diverse population of SPs, and the value and potential of anonymity.
Future Development: Once the framework of the remote SP program is developed, we will create, integrate, and evaluate the use of remote SP to impart knowledge and clinical skills training in medical school education via our NIAAA funded project.
Clinical skills assessment exams using Standardized patients (SPs) are an established component of medical school education, including the current USLME Step 2 CS exam™. The authors have developed a novel method for conducting SP encounters using web-based chat technology (e.g. Google® chat). “Remote Live Standardized Patient” (RLSP) interviews are conducted entirely online. The interview requires active learner participation focused on clinical skills, and represents a unique solution to teaching specific skills and affecting behavior. We are not aware of other educators using chat for this purpose. We have been pilot testing chat-based OSCE-style exams1,2 since 2007. In 2009 we have begun using RLSPs to teach skills, as well as evaluate them. The instructional RLSP key components include an interactive SP actor, an EMR like interface, and a “Hats Off” mode, which allows the student learner to “ask a preceptor” or research information during the encounter. Each learner’s performance is evaluated by standardized measures and by the RLSP actor feedback. This interactive, responsive web environment allows the RLSP interview to simulate a broad spectrum of learner/patient encounters, from initial screening through diagnosis and treatment.
Advantages include 1) decreased SP training cost and time commitment, 2) more flexible SP scheduling and recruiting since all encounters occur online, 3) elimination of face-to-face constraints of verisimilitude errors and correlation of actor physical appearance compared to the “patient”, and 4) instant availability of chat conversation transcripts for review and learner feedback. Potential limitations include missing the “whole person” experience afforded by face-to-face encounters, including the ability to assess body language and demonstrate physical exam skills. Since face-to-face SP encounters also suffer from realism limitations (i.e. the actor does not typically have the “patient's” presenting symptoms), we feel that the advantages of an RLSP balance and actually outweigh the drawbacks.
Use of web-based chat or its equivalent may have significant appeal to the current generation of Internet-savvy medical students. The RLSP experience appears to be a viable alternative to the traditional face-to-face SP interview, allows cost savings, and prepares students for Step 2 CS-style exams.
Introduction/Statement of the Problem: Successful treatment modalities for patients with co-morbid pain and substance abuse problems have been developed. However, the practice community is ill-equipped to incorporate such evidence-based recommendations or strong clinical consensus opinions due to a lack of knowledge and training in this area. Materials and Methods: Using funding from NIDA, this project is surveying and interviewing primary care physicians (PCPs), primary care residents, and nurse practitioners (NPs), to determine educational needs and learning preferences. We also inquired about interest in an educational experience involving Internet-based Standardized Patients (SPs) to mirror the challenges and variability of interviewing live patients. Exempt research determined by the Clinical Tools' IRB involved opt-in subjects who were contacted by email about participating in online surveys (n=9 for each group).
Results: Each group prioritized training need as follows: 1) treating patients in recovery, 2) treating patients actively using substances, 3) treating patients at risk for substance abuse. With respect to conventional online, case-based educational courses, each group preferred a format using multiple short cases (>75%). They differed slightly in terms of how to best integrate cases and factual content but all preferred interactive questions/answer pairs on every page. The majority of each group expressed interest in learning by interviewing a virtual SP. For the SP experience, a chat-based interview was
preferred to a video-based interview. Practicing physicians want very flexible hours and quick response time. Residents and NPs are more willing to wait for a response.
Conclusions: PCPs, residents and NPs identify a need to learn more about co-morbid substance abuse and pain. They are interested in online education solutions, especially those that employ multiple cases as the learning modality and interactive questions. They are willing to engage with virtual SP via chat.
Mitchell AM, Dewey CM. Chronic pain in patients with substance abuse disorder: general guidelines and an approach to treatment. Postrgrad Med. 2008;120(1):75-9 [http://www.ncbi.nlm.nih.gov/pubmed/18467812].
Idea: Medical educators interested in online learning have confidence in their ability to effect knowledge and the tools exist to demonstrate success. Yet, online learning is limited by the inability to show that the learning experience effects higher levels in Bloom's Taxonomy. How do we understand if an online course is succeeding beyond its
knowledge improvement goal?
Why the idea was necessary: Students took 5 online courses on the topic of addiction that were broken down into Prevalence, Detection and Diagnosis, Comorbidities, PCP Role, and Pharmacology. The courses demonstrated significant changes in knowledge in a very small sample (N=10) with p ranging from .033 to .001 and average knowledge scores improving from 14% to 52%. Self-efficacy too showed statistically significant improvement (p<.001) even with the very small sample. The students rated themselves as being able to effectively screen and detect opioid abuse following the learning experience. There was not enough of a difference in scores to detect a difference in attitudes and intended behavior. Unfortunately the standardized patient interview showed no change in clinical skills.
What was done: This project utilized a remote standardized patient (SP) experience to test, examine, and improve the learning. We planned to use the ratings of the SP experience to identify the weaknesses in student performance and modify the online learning to address them. After the first round of students completed the study, we looked at the data from both the Modified Skills Inventory (a subjective rating tool completed only by the standardized patient) and the Evaluator Rating Sheet (an objective checklist completed by both the standardized patient and an observer).
Evaluation: Results from the Modified Skills Inventory showed general improvement for all participants post-experience. However, the Evaluator Rating Sheet had some problematic areas; clinical areas which were expected to improve post-experience did not improve. Specifically, students consistently failed to screen the standardized patient using a standardized measure, such as the CAGE-AID. Mental status exams were also rarely conducted, and students showed difficulty in screening patients for psychiatric co-morbid conditions. We evaluated our existing curriculum, and found weaknesses in the level of detail paid to these areas. Pages covering these content areas were expanded to further
illustrate these teaching points.
Conclusions: A remote SP experience is a useful tool in the development of an online educational intervention. It can ensure that the student is truly mastering skills and integrating learning into their clinical experience framework.