A Case-Based Critical Care Curriculum for Internal Medicine Residents Addressing Social Determinants of Health

Learning by Doing, and Doing it Right - Building a Multi-Dimensional Social Determinants of Health Curriculum in a Rural Internal Medicine Residency

OBJECTIVES

While there has been increasing awareness of the importance of social determinants of health (SDOH) learning for internal medicine residents and physicians, only a few residency programs have incorporated training into their curricula. For those who did, the curricula were often didactic and lacked action-driven components or community partnership. Therefore, we built an experiential SDOH curriculum with an action-driven element and emphasis on community partnerships in a newly established residency program in rural New York.

METHODS

Over 24 months, 22 internal medicine residents were engaged in SDOH lectures, workshops, and action-driven learning through implementing screening tools in residency clinics and working with community partners. After the curriculum, residents' competency in addressing SDOH needs was assessed through Likert-scale questionnaires. Focused interviews were conducted among participating residents and faculty to obtain qualitative feedback on the curriculum.

RESULTS

Participating resident physicians demonstrated competency in recognizing and addressing SDOH needs after curriculum completion (mean competency score = 4.04). A significant increase in residents' self-rated confidence in addressing SDOH was observed after training (P = .002). Residents reported enhanced relationships with patients, effective utilization of community resources, and readiness to apply SDOH knowledge and skills to their future practice. Residents and faculty also discussed the SDOH challenges unique to rural primary care through their experiences.

CONCLUSION

This curriculum provides insights into an educational framework that improves residents' SDOH awareness, integrates SDOH into resident physicians' daily practice, and facilitates community collaboration. While challenges unique to rural primary care exist, this curriculum demonstrated the feasibility of longitudinal, action-driven, and community-centered SDOH education in rural areas that may inform future programs' curricular design.

Outcomes Associated With Airway Management of Adult Trauma Patients Admitted to Surgical Intensive Care

INTRODUCTION

Advanced airway management and ventilation of trauma patients are often needed during acute stabilization and resuscitation and later, in those admitted. In addition to endotracheal intubation for advanced airway management, tracheostomy is commonly used in critically ill patients when prolonged mechanical ventilation is required. However, the outcomes associated with airway management approaches and the timing of a tracheostomy in critically ill patients are mixed. This protocol intended to compare the effect of tracheostomy in major trauma patients vs. management with non-invasive techniques and endotracheal intubation during admission, examine complications and outcomes associated with the three types of airway management approaches, and explore the association of clinical and social determinants of health variables with complications in patients requiring advanced airway management.

METHODS

A total of 911 adult trauma patients admitted to a Level 1 trauma center surgical intensive care unit (SICU) were included in this retrospective, single-center, quantitative study from 2019 to 2021. Descriptive and correlational analyses were used to examine outcomes of ventilator days, length of stay, pneumonia, readmission, mortality, and associations with the airway management approach. The outcomes of ventilator days and length of stay were compared between groups with a one-way ANOVA, and differences between groups on outcomes of pneumonia, readmission, and mortality were estimated using crosstabulations and chi-square (x²) statistics. Hypothesized relationships of clinical and social determinants of health variables associated with outcomes of ventilator days, hospital length of stay, pneumonia, readmission, and mortality in patients requiring advanced airway management ≥ four days were estimated.

RESULTS

There was no significant difference in outcomes of pneumonia and mortality between the advanced airway management groups (p=0.856 and p=0.167, respectively). There were significant differences in ventilator days, length of stay (LOS), and readmission. Between the groups: endotracheal intubation only, early (<10 days post-intubation) tracheostomy, and late (>10 days post-intubation) tracheostomy in SICU patients (p <0.001, p=0.028, and p=0.003, respectively). Specifically, patients in the early tracheostomy group had a higher readmission rate (33.3%) as compared to endotracheal tube patients (2.3%) and late tracheostomy patients (0.0%). Social determinants of health variables (smoking and functional dependence) were also significantly correlated with readmission in the early tracheostomy and endotracheal tube airway management groups (p=.047 and p=.022, respectively). Additionally, clinical variables of injury severity scores, ED arrival systolic blood pressure (SBP), and presence of pre-existing comorbidities were found to be significantly associated with complications of pneumonia, readmission, and mortality within the patients (n=229) requiring advanced airway approaches.

CONCLUSION

Adult trauma patients with early tracheostomy airway management may experience a higher readmission rate related to the complexity of their injuries than patients managed with endotracheal intubation or late tracheostomy. Clinical and social determinants of health factors may be associated with complications. Further studies examining these associations in larger samples are needed to examine the validity of these findings.

Looking to "Level the Field": A Qualitative Study of How Clinicians Operationalize Social Determinants in Critical Care

Rationale: Current critical care practice does not integrate social determinants of health (SDOH) in systematic or standardized ways. Routine assessment of SDOH in the intensive care unit (ICU) may improve clinical decision making, patient- and family-centered outcomes, and clinician well-being. Objective: Given that the appropriateness and feasibility of SDOH assessment in the ICU is unknown, we aimed to understand how ICU clinicians think about and use SDOH. Methods: We conducted semistructured interviews with clinicians focused on barriers to and facilitators of assessing SDOH during critical illness and perceptions of screening for SDOH in the ICU. We used chart-stimulated recall to assist clinicians in reflecting on how SDOH applied to and was used in patients' care. After deidentifying interviews, we analyzed transcripts guided by a thematic analysis approach using a combination of inductive and deductive coding, the latter framed within the Centers for Disease Control and Prevention SDOH Healthy People framework. Results: We completed interviews with 30 clinicians in a variety of professional roles. The majority of clinicians self-identified as men (n = 17; 56.7%) of White race (n = 25; 83.3%). Clinicians contextualize their use of SDOH within three frames of reference: 1) their own identity and experiences; 2) their relationships and communication with patients and caregivers; and 3) immediate structures of care around ICU patients, including clinician advocacy, care transitions, and readmission. Clinicians identified that discussing SDOH could allow them to recognize bias faced by their patients, elucidate drivers of critical illness, and navigate communication with patients' caregivers. Clinicians worried about ICU-specific factors impeding the discussion of SDOH, including time constraints and acuity, high stakes and emotions, and negative anticipatory emotions. Conclusions: Clinicians gather SDOH during critical illness both to understand their patients' stories and to provide individualized care, which may lead to better clinician satisfaction and patient- and family-centered care outcomes. Educational and operational efforts to increase SDOH assessment and use in critical care should also gather and integrate the perspectives of patients and caregivers regarding the collection and use of SDOH in the ICU.

Integrating the social determinants of health into graduate medical education training: a scoping review

BACKGROUND

The social determinants of health (SDH) play a key role in the health of individuals, communities, and populations. Academic institutions and clinical licensing bodies increasingly recognize the need for healthcare professionals to understand the importance of considering the SDH to engage with patients and manage their care effectively. However, incorporating relevant skills, knowledge, and attitudes relating to the SDH into curricula must be more consistent. This scoping review explores the integration of the SDH into graduate medical education training programs.

METHODS

A systematic search was performed of PubMed, Ovid MEDLINE, ERIC, and Scopus databases for articles published between January 2010 and March 2023. A scoping review methodology was employed, and articles related to training in medical or surgical specialties for registrars and residents were included. Pilot programs, non-SDH-related programs, and studies published in languages other than English were excluded.

RESULTS

The initial search produced 829 articles after removing duplicates. The total number of articles included in the review was 24. Most articles were from developed countries such as the USA (22), one from Canada, and only one from a low- and middle-income country, Kenya. The most highly represented discipline was pediatrics. Five papers explored the inclusion of SDH in internal medicine training, with the remaining articles covering family medicine, obstetrics, gynecology, or a combination of disciplines. Longitudinal programs are the most effective and frequently employed educational method regarding SDH in graduate training. Most programs utilize combined teaching methods and rely on participant surveys to evaluate their curriculum.

CONCLUSION

Applying standardized educational and evaluation strategies for SDH training programs can pose a challenge due to the diversity of the techniques reported in the literature. Exploring the most effective educational strategy in delivering these concepts and evaluating the downstream impacts on patient care, particularly in surgical and non-clinical specialties and low- and middle-income countries, can be essential in integrating and creating a sustainable healthcare force.

Implementation of Formal Curriculum on Health Care Disparities in Military Family Medicine Residency

BACKGROUND AND OBJECTIVES

The Accreditation Council for Graduate Medical Education (ACGME) requires education on health care disparities (HCD), but research assessing formal curricula is limited. To improve knowledge and confidence in HCD, the family medicine residency program at Darnall Army Medical Center implemented a formal HCD curriculum.

METHODS

During the 2021-2022 academic year, starting July 2021, a formal HCD curriculum was implemented for family medicine residents and faculty. Ten lectures on HCDs and implicit bias were given over the course of the year. Residents and faculty were asked to incorporate HCD into their regular continuing medical education lectures. ACGME survey data as well as a pre- and postcurriculum survey were used to assess HCD knowledge and confidence. Descriptive statistics and a paired-sample t tests were calculated to compare pre- to postcurriculum changes.

RESULTS

The percentage of residents who reported that they had received HCD education increased from 72% on the 2021 ACGME survey to 100% in 2022 (N=18). We found a significant (P<.05) improvement in knowledge and confidence across 11 of 12 questions on the pre- and postcurriculum survey.

CONCLUSIONS

A formal curriculum in a military family medicine residency setting was effective for improving self-reported HCD knowledge and confidence.

Cased-based education rounds-the eternal heart of an international training program

Case-based teaching or "Morning Rounds" have been used in medical education for more than a century and remain a cornerstone for teaching in many training programs. Our Pediatric Critical Care Medicine (PCCM) program was established forty years ago and has retained this form of teaching since its inception. Case-based rounds have consistently had the highest evaluation of all curricula in our program. Here we review the history of how these rounds were introduced in medical education, provide data from the learners' evaluation of these case-based rounds, and discuss the strengths and potential drawbacks of this form of teaching from an educational theories perspective with the hope that they can be used by other Pediatric Critical Care training programs.

An Opportunity for Change: Principles for Reforming Internal Medicine Inpatient Conferences

Inpatient educational conferences are a key part of internal medicine residency training. Many residencies made conferences virtual during the COVID-19 pandemic, and are now returning to in-person sessions. As we navigate this change, we can seize this opportunity to re-evaluate the role that inpatient conferences serve in resident education. In this paper, we briefly review the history of inpatient educational conferences before offering five recommendations for improvement. Our recommendations include grounding conference formats in educational theory, leveraging the expertise of all potential educators, broadening content to include health equity and justice throughout all curricula, and explicitly focusing on cultivating community among participants. Recognizing that each residency program is different, we anticipate that these recommendations may be implemented differently based on program size, available resources, and current institutional practices. We also include examples of prior successful curricular reforms aligned with our principles. We hope these recommendations ensure inpatient conferences continue to be a central part of residency education for future generations of internal medicine residents.

Educational Outcomes of Diversity Curricula in Graduate Medical Education

Background

Education is an important step toward achieving equity in health care. However, there is little published literature examining the educational outcomes of curricula for resident physicians focused on diversity, equity, and inclusion (DEI).

Objective

Our objective was to review the literature to assess the outcomes of curricula for resident physicians of all specialties focused on DEI in medical education and health care.

Methods

We applied a structured approach to conducting a scoping review of the medical education literature. Studies were included for final analysis if they described a specific curricular intervention and educational outcomes. Outcomes were characterized using the Kirkpatrick Model.

Results

Nineteen studies were included for final analysis. Publication dates ranged from 2000 to 2021. Internal medicine residents were the most studied. The number of learners ranged from 10 to 181. The majority of studies were from a single program. Educational methods ranged from online modules to single workshops to multiyear longitudinal curricula. Eight studies reported Level 1 outcomes, 7 studies reported Level 2 outcomes, 3 studies reported Level 3 outcomes, and only 1 study measured changes in patient perceptions due to the curricular intervention.

Conclusions

We found a small number of studies of curricular interventions for resident physicians that directly address DEI in medical education and health care. These interventions employed a wide array of educational methods, demonstrated feasibility, and were positively received by learners.

Integrating social determinants into pharmacotherapy courses: A case-based learning approach

BACKGROUND

The recognition of social determinants as major drivers of health outcomes has important implications for health care providers, including pharmacists. It is therefore imperative that providers have the requisite knowledge, skills, and attitudes to adequately address the contributions of social determinants of health (SDOH) alongside the impact of medical care on health and treatment outcomes. Case-based learning is a common practice in pharmacy education. Patient cases used in pharmacotherapy courses typically highlight clinical parameters and quantitative indices, often to the exclusion of sociocultural contexts. In actual practice, pharmacists (and other health care providers) must consider both clinical information and the context of SDOH in order to deliver responsive and effective patient care.

EDUCATIONAL ACTIVITY AND SETTING

The aim of the project was to build patient cases that reflect both aspects. The intent is to use these cases in the core pharmacy curriculum to teach students how to concurrently consider both clinical and social elements in patient care. Eleven pharmacists and educators participated in three work groups to develop 10 cases for pharmacotherapy courses in cardiovascular disease, diabetes management, and mental health. Two of the cases were facilitated with fourth year students on advanced pharmacy practice experiences.

SUMMARY

Feedback from case developers and students highlights features of the cases that lend them to utility in the pharmacy curriculum. The integration of SDOH in patient cases provides opportunity for students to build the relevant competencies that will enable them to provide holistic patient care.