Milwaukie Family Medicine 2024

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  Development of Addiction Medicine Selective Curriculum

  Kelsey Andrew and Tanya Page

  Context or Background: Substance use disorder is a growing program across America. It is important that we as primary care physicians are well trained and comfortable treating these conditions. ACGME has also prioritized this area of resident learning. In order to both create better educated doctors and also follow guidelines placed by the ACGME, we have worked to develop an addiction medicine focused four weeks selective to increase resident comfort in diagnosing and treating patients with substance use disorders. Goals and Objectives: To increase resident comfort with diagnosing and treating patients with substance use disorders across the lifespan and in multi-ple settings Methods: a literature review was completed and following this, a curriculum was developed with the goal of including multiple settings, patient populations, and use disorders. We utilized existing residency experiences such as our ItMatters program for patients in our own clinics with substance use disorder, as well as Project Nuture which treats pregnancy and post-partum women with substance use disorder. We will continue our existing relationship with addiction medicine inpatient consult services at PPMC. We also expanded to integrate working with Clackamas County health regarding their sublocade clinic and working with their behavioral health staff. We will also be including time at Great Circle, which is a program focused on treating Native America and First people with substance use disorder. Finally, we will also plan to utilize online modules and resident teaching opportunities to round out the selective experience. Assessment methods or Results: The curriculum will be implemented in the 2024-2025 academic year. Currently, there are 9 residents who have signed up for the addiction medicine selective for the next year who will complete pre and post surveys to assess if the selective has met objectives and increased resident comfort and knowledge when caring for patients with substance use disorder. Discussion/Conclusions/Next Steps: To develop an addiction medicine curriculum that will increase provider comfort across multiple settings, the new curriculum needs to include resident exposure to multiple settings. With our new curriculum, this includes inpatient consult management, outpatient management and working with a variety of patient populations including pregnant and patients of different ethnic backgrounds. Having a month-long focus on this information in a variety of settings aims to improve resident confidence and comfort with treating a variety of substance use disorders including alcohol use disorder, opiate use disorder, tobacco use disorder, and stimulant use disorder. For the next steps, the curriculum will be initiated and evaluated by each resident who completes the selective. Each resident who participates in the selective will be asked to complete a pre and post survey to assess academic and clinical growth when treating people with substance use disorders. Further adjustments may be made to the curriculum based on feed-back and rotation availability.

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  Developing an integrative Medicine Elective for a Family Medicine Residency

  Brian Bizub and Melissa Hemphill

  Background: Integrative medicine includes complementary and alternative (CAM) such as acupuncture, tai chi, yoga, vitamins, herbs, and other traditional healing practices. According to the CDC, 36.7% of Americans utilize CAMs. Because of this, integrative medicine experiences have become more common in medical residencies. We set out to design a four week integrative medicine elective for Providence Milwaukie Family Medicine Residency Program. Methods: A review of integrative medicine elective curricula from other medical residency programs was performed. A needs assessment was developed based on this review to generate possible learning objectives, learning experiences, and types of integrative medicine providers that residents would prefer to work with in an elective experience. The needs assessment was disseminated to all resident physicians at Providence Milwaukie Family Medicine Residency. Results: 80% of respondents indicated that they would be interested in participating in an integrative medicine elective. Residents identified observing how physicians incorporate integrative medicine into their practice as the most important learning objective. The most important learning activity to further learning about integrative medicine was working with integrative medicine providers. Residents identified physicians who use integrative medicine techniques, physicians who practice osteopathic manipulation, and naturopaths as providers who they would most like to work with during the elective. Conclusions: Residents have demonstrated clear interest in taking a four week integrative medicine elective. They identified that the most important learning experience would be to work with integrative medicine providers, particularly with physicians who incorporate integrative medicine into their practice. Current efforts are now underway to connect with physicians and other integrative medicine providers in the community so residents can work with them during the elective. These experiences will be paired with a core online didactive curriculum created by the Andrew Weil Center for Integrative Medicine.

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  Nutrition Elective Impact on Resident Competency

  Andrew W. Duchesne, Jill Christensen, Heidi Davis, Kara Castro, and Charlotte Navarre

  Context/background: Nutrition is the number one risk factor contributing to death in the United States, and yet healthcare providers report not receiving ade-quate education to provide effective patient counseling. Primary care providers are perfectly situated in the healthcare continuum to provide evidence-based nutrition-al counseling to patients, as well as screen for and intervene on food insecurity. Objective: Main objective: evaluate the impact of a structured nutritional elective on Family Medicine residents’ competency regarding evidence-based nutritional counseling. Secondary objective: evaluate impact on competency screening for and intervening on food insecurity. Methods: Design: pre- and post-elective survey evaluating 5 domains on a scale of 1-5 (1 being low, 5 being high): 1) knowledge of key nutritional requirements and evidence-based recommendations, 2) comfort providing data/statistics around diet-related health complications and counseling about specific dietary needs, 3) comfort screening for food insecurity, 4) knowledge to intervene on food insecuri-ty, 5) knowledge of Providence-specific resources for food insecurity and how to access them. Setting: Providence Milwaukie Community Teaching Kitchen Participants: 4 family medicine residents from Providence Milwaukie Intervention: structed elective consisting of at least 7 half days. First half day is 4-hour online CME course through Gaples institute: Nutrition Science for Health and Longevity: What Every Physician Needs to Know. Subsequent half days spent rotating with Providence Milwaukie Teaching Kitchen, including time with Regis-tered Dietitian/Certified Diabetes Care and Education Specialist, Patient Navigator screening and addressing food insecurity, food pharmacy distribution, working in community garden, participating in culinary medicine classes. Results: Post-elective survey showed statistically significant improvement across all domains (all with p-values < 0.05). Averages for the following domains [pre -> post]: 1) [1.5 -> 4.5], 2) [ 1.5 -> 4], 3) [2 -> 5], 4) [2.25 -> 5], 5) [2 -> 5]. Discussion/conclusions: Nutrition is one of the most important factors affecting our patients’ health, and yet many providers do not feel adequately trained to coun-sel patients effectively. A structed nutrition elective was shown to improve family medicine resident competency providing evidence-based nutrition recommenda-tions. Secondarily, it was also shown to improve comfort screening for and knowledge of how to intervene on food insecurity.

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  Improving Pediatric Fluoridation at Providence Southeast Family Medicine

  Iman Malik, Brian Bizub, Andrew Tobler, and Ben Pederson

  Dental caries are the most common preventable chronic condition effecting children worldwide. The patient population at Providence Southeast Family Medicine (PMG SE) are disproportionally affected by high caries rates due to lack of fluorinated water supply, low socioeconomic status, and limited access to pediatric dental services. Although application of topical fluoride is an effective strategy for prevention of caries, it is not routinely completed during office visits. PMG SE did not have an established workflow for fluoride application in clinic. We implemented a quality improvement (QI) project to increase the rate of fluoride application in children ages 6 months through 5 years old during Well Child Checks (WCCs) to a target of a 25% success rate. We completed a detailed root cause analysis and stakeholder interviews that informed the development of our QI project. Through a series of four Plan-Do-Study-Act (PDSA) cycles, we implemented a new clinical workflow to improve process measures of 1) provider education, 2) identifying eligible patients, 3) provider and medical assistant reminders through chart scrubbing, and 4) providing parent education. We achieved our target of successfully applying fluoride for 25% of WCCs after PDSA #1 and sustained a success rate of greater than 40% by the end of completion of PDSA #4. This project demonstrates the impact and success of implementing a simple workflow within the outpatient clinical setting to improve dental health for our at-risk patient population.

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  Empowering Partners: Developing a Companion Program for Partners of Project Nurture

  Peter St. George

  Background: Project Nurture is a successful comprehensive program for pregnant people with substance use disorder that provides substance use treatment, prenatal care, in-hospital deliveries, ensuing postnatal care and pediatric care for the newborn. There currently is no complementary program to support the partners of those in Project Nurture, referred to inclusively and without gender as “fathers”. Objective: To develop a potential program structure for fathers that provides similar services to and is complementary with Project Nurture Providence Milwaukie. Methods: Via literature review, a qualitative survey of current Project Nurture patients, a needs assessment and assessment of existing services, we have identified gaps in care and propose a potential intervention. Results: Research evaluated revealed a strong connection between fathers with substance use disorder and suboptimal parenting skills and negative impacts on the child and mother. The survey of Project Nurture patients indicated a strong demand for father-supporting care, however no current programs in Portland meet this need. Nationally, several programs combine substance use treatment, parenting skills and social support. Additionally, Providence Milwaukie Family Medicine’s It MATTERS clinic is a virtual clinic treating those with substance use disorder. Conclusion: There is a clear link between fathers with substance use disorder and both suboptimal parenting skills and negative effects on their children and partners; however, no current programs locally address this. We propose a Project Nurture companion program serving fathers at Providence Milwaukie which integrates the pre-existing It MATTERS program with a parenting preparation and support program. Next steps for this project may include detailed program development and implementation and evaluation of a pilot program.

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  A Novel Method of Buprenorphine Induction Utilizing Buprenorphine extended-released Subcutaneous injection, intranasal naloxone and sublingual buprenorphine: A case report

  Peter St. George, Josh Reagan, and Kasey Edwards Snider

  Background: Current buprenorphine induction protocols were developed to treat heroin and prescription opioid use disorder. When applied to fentanyl, they are often unsuccessful. A new method for inducing buprenorphine called QuickStart involves simultaneous administration of intranasal naloxone and sublingual buprenorphine, with the ensuing withdrawal symptoms treated with additional sublingual buprenorphine. Administering buprenorphine extended-release subcutaneous injection (Sublocade) prior to QuickStart induction has not been detailed in medical literature. Objective: To describe a novel buprenorphine induction method utilizing Sublocade, intranasal naloxone and sublingual buprenorphine in a patient with fentanyl use disorder. Methods: Information was obtained by electronic medical record review, participation in the buprenorphine induction, interviews with the patient, and literature review. The patient read and signed an informed consent form, was provided a manuscript, and authorized publication. Results: A 22-year-old woman with fentanyl use disorder was induced on buprenorphine in our family medicine clinic with a combination of Sublocade, intranasal naloxone and sublingual buprenorphine. She experienced the expected precipitated withdrawal which peaked at thirty minutes and resolved at two hours. Reassessment at two months post-induction showed no return to fentanyl use and the patient has received regular administrations of Sublocade. Conclusion: Presented is the case of a patient who was treated in an ambulatory family medicine clinic for fentanyl use disorder with a novel buprenorphine induction method utilizing Sublocade followed by simultaneous administration of naloxone and sublingual buprenorphine. She has not returned to fentanyl use. This buprenorphine induction method may benefit patients unable to tolerate current buprenorphine induction methods and increases short-term buprenorphine compliance.

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  Development of Behavioral Health “Selective”: A Response to New ACGME Requirements

  Iman Malik and Jen Hill

  Context or Background: Providence Oregon Family Medicine Residency has set out to create 5 individual elective tracks, called “selectives”, both in response to the ACGME’s increased requirement for elective time in AY 2024-2025 and as a way to provide intensive learning in highly relevant content areas for resident and early-career physicians. This poster presentation details the process of creating one of these elective tracks, the Behavioral Health selective. Goals and Objectives: • Share a structure to adapt a current curriculum to meet new ACGME requirements • Describe an approach to identify local community partners that could collaborate with their program to provide well rounded education to residents • Begin designing elective curricula that provide a robust experience for residents in relevant topics Methods: Senior residents, collaborating with faculty members, in-house multidisciplinary teams and community partners, have taken on the task of completing a needs assessment, establishing local partnerships and creating curricula that are both logistically sustainable for the program and educationally enriching for future residents without burdening them with the task of having to find 6 months of learning opportunities. Current research also points to the need for such learning. “In the context of policy and care delivery changes, equipping primary care providers to address mental health needs is crucial.” (1) Discussion/Conclusions/Next Steps: These curricula will be rolled out in AY 2024-2025 with further plans to assess their impact via pre and post selective surveys. Surveys will be disseminated electronically and will collect self report data on residents’ comfort treating patients with depression, anxiety, insomnia, PTSD, and SPMI. The post survey also elicits self report data on the relevance, practice-impact, and suggested improvements for the selective. References: 1. Physician Quality Information | Health Affairs. (n.d.). https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2019.00375

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  Improving Resident Education Regarding Inpatient Emergency Situations

  Robell Morehouse

  Context or Background: Family Medicine residencies are required to provide their residents with robust inpatient education and clinical experience. Emergency situations are an integral part of inpatient medicine and improved education regarding these situations can lead to improved patient safety/clinical outcomes & decrease resident wellness surrounding these stressful situations. Most of our formal education surrounding emergency situations is regarding code blues and ACLS management which leaves an educational gap surrounding rapid response teams (RRTs). Objectives: The goal of my project is to improve education surrounding RRTs, specifically by developing a framework to approach RRTs & develop practice opportunities Methods: Formal education via afternoon of multidisciplinary didactics, practice cases, dot-phrases Discussion/Conclusions/Next Steps: Additional practice case development, orientation presentation or noon report

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  Point of care Ultrasound (POCUS) Curriculum: A Needs Assessment

  Andrew Tobler

  Background: The ACGME, in the most recent changes, has implemented that all Family Medicine programs are to include ultrasound or POCUS training. We have historically had residents with an interest in POCUS who have completed self-directed learning but have not yet formed a formal curriculum. Objective: To assess the educational needs for a POCUS curriculum using a needs assessment survey which included current residents and faculty Methods: Utilizing guidance from AAFP regarding proposed training topics and structuring a curriculum utilizing Kern’s 6 step curriculum design, a survey of eight-questions was submitted to faculty and residents. The focus was to assess the respondents, role within the residency, experience in POCUS, where experience was gained, which scans or systems are most meaningful, number of scans preformed in the last 3 months and barriers in competency and practicing. Results: 23 total respondents; 10 faculty and 13 residents responded to the survey. 69% of respondents selected being extremely interested or very interested in learning additional POCUS skills. 90% of respondents selected being somewhat familiar or less when assessing their experience. Most acquired experience came from medical school, online training courses, and faculty development courses. 95% of respondents selected POCUS as a tool that should be utilized in practice. When assessing recent usage in the last 3 months; 5% responded to 0 scans, 45% 1-3 scans, 15% 4-9 scans, and 15% 10+ scans. Respondents selected OBGYN, MSK/soft tissue, bladder scan, and volume assessment as the most important scans to achieve proficiency in. The biggest barrier to integration, agreed upon by 86% of respondents, was lack of confidence in obtaining the correct image followed by an inability to interpret images and the lack of an ultrasound pathway or curriculum to obtain and maintain POCUS practice and skills. Conclusion: The importance of POCUS training was widely agreed upon although our internal skill, usage and experience vary. Understanding the barriers to perceived competency and curriculum efforts can be made to improve confidence in image acquisition and interpretation through a structured curriculum to improve collective POCUS skill. Next steps: • Using previously successful curriculum development methods, a POCUS curriculum will be implemented in 2 to 3 years implementing didactic, hands on and • independent learning styles with a focus on OBGYN, POCUS, bladder, and volume assessment. • Efforts will be made to train internal faculty to have expertise to train residents and faculty • Enhance and form relationships across disciplines who utilize POCUS • Dr. Bin Chen PGY-2 will continue the implementation of preliminary curriculum development • Post implementation survey