Border Health Training for Family Physicians: Is There a Need and Interest?

BACKGROUND AND OBJECTIVES

The United States-Mexico border has unique health care challenges due to a range of structural factors. Providers must be trained to address these barriers to improve health outcomes. Family medicine as a specialty has developed various training modalities to address needs for specific content training outside of core curriculum. Our study assessed perceived need, interest, content, and duration of specific border health training (BHT) for family medicine residents.

METHODS

Electronic surveys of potential family medicine trainees, faculty, and community physicians assessed appeal, feasibility, preferred content, and duration of BHT. We compared responses from participants from the border region, border states and the rest of the United States in their opinions about modality, duration, content of training, as well as perceived barriers.

RESULTS

Seventy-four percent of survey participants agreed that primary care on the border is unique; 79% indicated a need for specialized BHT. Most border-region faculty were interested in participating as instructors. Most residents expressed interest in short-term rotation experience, yet most faculty recommended postgraduate fellowship. Respondents selected language training (86%), medical knowledge (82%), care of asylum seekers (74%), ethics of cross-cultural work (72%), and advocacy (72%) as the top-five needed training areas.

CONCLUSIONS

Results of this study indicate a perceived need and sufficient interest in a range of BHT formats to warrant developing additional experiences. Developing a variety of training experiences can engage a wider audience interested in this topic; that should be done in a way ensuring maximum benefit to border-region communities.

Using Simulation-Based Learning with Standardized Patients (SP) in an Implicit Bias Mitigation Clinician Training Program

Objectives

To describe the development and refinement of an implicit bias recognition and management training program for clinical trainees.

Methods

In the context of an NIH-funded clinical trial to address healthcare disparities in hypertension management, research and education faculty at an academic medical center used a participatory action research approach to engage local community members to develop and refine a "knowledge, awareness, and skill-building" bias recognition and mitigation program. The program targeted medical residents and Doctor of Nursing Practice students. The content of the two-session training included: didactics about healthcare disparities, racism and implicit bias; implicit association test (IAT) administration to raise awareness of personal implicit bias; skill building for bias-mitigating communication; and case scenarios for skill practice in simulation-based encounters with standardized patients (SPs) from the local community.

Results

The initial trial year enrolled n  =  65 interprofessional participants. Community partners and SPs who engaged throughout the design and implementation process reported overall positive experiences, but SPs expressed need for greater faculty support during in-person debriefings following simulation encounters to balance power dynamics. Initial year trainee participants reported discomfort with intensive sequencing of in-person didactics, IATs, and SP simulations in each of the two training sessions. In response, authors refined the training program to separate didactic sessions from IAT administration and SP simulations, and to increase safe space, and trainee and SP empowerment. The final program includes more interactive discussions focused on identity, race and ethnicity, and strategies to address local health system challenges related to structural racism.

Conclusion

It is possible to develop and implement a bias awareness and mitigation skills training program that uses simulation-based learning with SPs, and to engage with local community members to tailor the content to address the experience of local patient populations. Further research is needed to measure the success and impact of replicating this approach elsewhere.

COmmuNity-engaged SimULation Training for Blood Pressure Control (CONSULT-BP): A study protocol

BACKGROUND

Healthcare professionals have negative implicit biases toward minority and poor patients. Few communication skills interventions target implicit bias as a factor contributing to disparities in health outcomes. We report the protocol from the COmmuNity-engaged SimULation Training for Blood Pressure Control (CONSULT-BP), a trial evaluating a novel educational and training intervention targeting graduate medical and nursing trainees that is designed to mitigate the effects of implicit bias in clinical encounters. The CONSULT-BP intervention combines knowledge acquisition, bias awareness, and practice of bias mitigating skills in simulation-based communication encounters with racially/ethnically diverse standardized patients. The trial evaluates the effect of this 3-part program on patient BP outcomes, self-reported patient medication adherence, patient-reported quality of provider communication, and trainee bias awareness.

METHODS

We are conducting a cluster randomized trial of the intervention among cohorts of internal medicine (IM), family medicine (FM), and nurse practitioner (NP) trainees at a single academic medical center. We are enrolling entire specialty cohorts of IM, FM, and NP trainees over a 3-year period, with each academic year constituting an intervention cycle. There are 3 cycles of implementation corresponding to 3 sequential academic years. Within each academic year, we randomize training times to 1 of 5 start dates using a stepped wedge design. The stepped wedge design compares outcomes within training clusters before and after the intervention, as well as across exposed and unexposed clusters. Primary outcome of blood pressure control is measured at the patient-level for patients clustered within trainees. Eligible patients for outcomes analysis are: English-speaking; non-White racial/ethnic minority; Medicaid recipient (regardless of race/ethnicity); hypertension; not have pregnancy, dementia, schizophrenia, bipolar illness, or other serious comorbidities that would interfere with hypertension self-control; not enrolled in hospice. Secondary outcomes include trainee bias awareness. A unique feature of this trial is the engagement of academic and community stakeholders to design, pilot test and implement a training program addressing healthcare.

DISCUSSION

Equipping clinicians with skills to mitigate implicit bias in clinical encounters is crucial to addressing persistent disparities in healthcare outcomes. Our novel, integrated approach may improve patient outcomes.

TRIAL REGISTRATION

NCT03375918.

PROTOCOL VERSION

1.0 (November 10, 2020).

Characterizing a community health partnership in Dominican Republic: Network mapping and analysis of stakeholder perceptions

BACKGROUND

Medical trainees complete learning experiences abroad to fulfil global health curricular elements, but this participation has been steadily criticized as fulfilling learner objectives at the cost of host communities. This study uses network and qualitative analyses in characterizing a community coalition in order to better understand its various dimensions and to explore the perceived benefits it provided towards optimizing community outcomes.

METHODS

Data from a semi-structured survey was used for network and qualitative analyses. Partner linkages were assessed using network analysis tool UCINET 6 (version 6.6). Thematic analysis was conducted on qualitative responses around the perceived coalition strengths and weaknesses.

RESULTS

Network analysis confirmed that local member organizations were key network influencers based on reported formal agreements, general interactions, and information shared. While sharing of resources was rare, qualitative analysis suggested that information sharing contributed to engagement, enthusiasm, and communication that allowed visiting partners to expand their understanding of community needs and shift their focus beyond learner objectives.

CONCLUSION

Global health programs for medical students should consider the use of community health coalitions to optimally align the work undertaken by learners on global health experiences abroad. Network mapping can help educators and coalition partners visualize interactions and identify value.

An Assessment of International Family Medicine Faculty Development Priorities: Perspectives From the American Academy of Family Physicians Global Health Workshop

Introduction

The proliferation of new family medicine training programs across the globe has increased the demand for faculty development (FD) opportunities in international settings. US-based faculty may partner with international colleagues to support FD. In 2016, the Society of Teachers of Family Medicine Global Health Educators Collaborative (STFM-GHEC) began to develop a toolkit of low-cost FD resources for this purpose. To ensure that the resources appropriately target current FD needs, STFM-GHEC organized a session at the 2016 American Academy of Family Physicians (AAFP) Global Health Workshop (GHW) to collect feedback from internationally-based and US-based faculty.

Methods

The authors presented a list of faculty development topics to attendees of an AAFP GHW session entitled "Global Faculty Development Tool Kit" on September 8, 2016, in Atlanta, Georgia. Workshop participants voted up to five times each using sticky notes for the topics they felt were of greatest need.

Results

Forty-five participants cast 157 votes (34 from internationally-based faculty, 123 from US-based faculty). The combined group ranked curriculum development, program evaluation, and teaching methods as the most important FD needs. Both groups identified assessment strategy and time management among the least important FD needs. Other topics such as technology training and research design varied widely between the two groups in relative importance.

Conclusions

This pilot demonstrates that US-based and internationally-based family medicine faculty may differ in their perceived FD needs. This exercise may be utilized by future members in global health partnerships to understand and prioritize faculty development needs.

Family Medicine Global Health Fellowship Competencies: A Modified Delphi Study

BACKGROUND AND OBJECTIVES

Many US medical schools and family medicine departments have responded to a growing interest in global health by developing global health fellowships. However, there are no guidelines or consensus statements outlining competencies for global health fellows. Our objective was to develop a mission and core competencies for Family Medicine Global Health Fellowships.

METHODS

A modified Delphi technique was used to develop consensus on fellowship competencies. A panel, comprised of 13 members with dual expertise in global health and medical education, undertook an iterative consensus process, followed by peer review, from April to December 2014.

RESULTS

The panel developed a mission statement and identified six domains for family medicine global health fellowships: patient care, medical knowledge, professionalism, communication and leadership, teaching, and scholarship. Each domain includes a set of core and program-specific competencies.

CONCLUSION

The family medicine global health competencies are intended to serve as an educational framework for the design, implementation, and evaluation of individual family medicine global health fellowship programs.

Coalicion de Salud Comunitaria (COSACO): using a Healthy Community Partnership framework to integrate short-term global health experiences into broader community development

Background

There is growing concern that short-term experiences in global health experiences (STEGH), undertaken by healthcare providers, trainees, and volunteers from high income countries in lower and middle income countries, risk harming the community by creating a parallel system of care separate from established community development efforts. At the same time, the inclusion of non-traditional actors in health planning has been the basis of the development of many Healthy Community Partnerships (HCP) being rolled out in Canada and the United States. These partnerships aim to bring all stakeholders with a role to play in health to the table to align efforts, goals and programs towards broad community health goals.

Results

This methodology paper reports on the process used in La Romana, Dominican Republic, in applying a modified HCP framework. This project succeeded at bringing visiting STEGH organizations into a coalition with key community partners and supported attempts to embed the work of STEGH within longer-term, established development plans.

Conclusions

In presenting the work and process and lessons learned, the hope is that other communities that encounter significant investment from STEGH groups, and will gain the same benefits that were seen in La Romana with regards to improved information exchange, increased cross-communication between silos, and the integration of STEGH into the work of community partners.

Enhanced facilitation of spatial attention in schizophrenia

OBJECTIVE

While attentional functions are usually found to be impaired in schizophrenia, a review of the literature on the orienting of spatial attention in schizophrenia suggested that voluntary attentional orienting in response to a valid cue might be paradoxically enhanced. We tested this hypothesis with orienting tasks involving the cued detection of a laterally presented target stimulus.

METHOD

Subjects were chronic schizophrenia patients (SZ) and matched healthy control subjects (HC). In Experiment 1 (15 SZ, 16 HC), cues were endogenous (arrows) and could be valid (100% predictive) or neutral with respect to the subsequent target position. In Experiment 2 (16 SZ, 16 HC), subjects performed a standard orienting task with unpredictive exogenous cues (brightening of the target boxes).

RESULTS

In Experiment 1, SZ showed a larger attentional facilitation effect on reaction time than HC. In Experiment 2, no clear sign of enhanced attentional facilitation was found in SZ.

CONCLUSIONS

The voluntary, facilitatory shifting of spatial attention may be relatively enhanced in individuals with schizophrenia in comparison to healthy individuals. This effect bears resemblance to other relative enhancements of information processing in schizophrenia such as saccade speed and semantic priming.

Word priming in schizophrenia: associational and semantic influences

We examined semantic vs. associational influences on word priming in schizophrenia. Tested on three occasions, subjects made speeded lexical decisions to three kinds of prime-word relationships: semantic-only (e.g., Deer-Pony), associated-only (e.g., Bee-Honey), or semantic-and-associated (e.g., Doctor-Nurse). Controls showed greater priming of words related via two relationships (semantic-and-associated) than for words related only semantically.. However, patients showed greater priming for associated-only words than for words related only semantically. Schizophrenic patients may show an associational bias, restricting semantic integration and contributing to their disturbed thinking.