Transcript Wamsley 2014

Maria A. Wamsley, MD
Professor of Clinical Medicine
UCSF School of Medicine
Scott Steiger, MD
Nathaniel Gleason, MD
Katherine A. Julian, MD
Patricia O’Sullivan, EdD
Michelle Guy, MD
Jason Satterfield, PhD
Funding: SAMHSA grant U79T1020295
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Barriers exist to implementation of SBIRT
into clinical practice
◦ Provider knowledge and skills
◦ Time pressures in the clinical setting
◦ Lack of referral resources

SBIRT curricula can address knowledge and
skills
◦ Improved knowledge, attitudes, confidence1,2
◦ Improved performance on standardized patient
assessments3,4
Does
Shows
Knows How
Knows
Chart-Stimulated Recall (CSR)
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Uses medical record to stimulate learner
recollection of the encounter and explore
rationale behind clinical decisions5
Electronic Health Record (EHR)
Tools
Ready access to knowledge at the
point-of-care
 Reinforce previously learned skills
 Facilitate documentation
 Provide tailored resources
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How do residents use SBIRT skills in clinical
practice as documented in patient charts?
How do residents think about SBIRT as
revealed through a chart stimulated recall?
How do residents use EHR SBIRT clinical tools
in practice?
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5 hour curriculum for primary care internal
medicine residents (PGY2/PGY3)
◦ Intro to SBIRT
◦ Brief Intervention/MI skills
◦ Pharmacologic management of addiction
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EHR Tools
◦ History of Present Illness (HPI)
◦ Assessment and Plan (A/P)
◦ Patient Information Resources (PI)
Patient List
3 Patients
(drinking at or
above
recommended
limits)
Faculty
completed 24item checklist
CSR with
faculty
member
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One-on-One meeting with faculty member
Structured interview guide
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Identify barriers to addressing alcohol use
Where alcohol fit into visit priorities
Resident assessment of alcohol use
Whether BI strategies were used
Use of EHR tools
How resident would approach case differently in
future
Feedback provided to resident
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Percentages calculated for each checklist item
Qualitative analysis of CSR interview notes
◦ Generated preliminary code list
◦ Subset of notes coded and code list refined and
finalized
◦ All notes were double-coded by two faculty
members
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20 PGY2 and PGY3 residents participated in
the curriculum
18 participated in the CSR
38 charts met eligibility criteria and were
included in the study
90
80
70
60
50
40
30
20
10
0
Resident
Knowledge
Patient
Systems
Denial
Lack of honesty
Time
Medical Comorb
Skills
Mental Health Comorb
Willingness to engage
Unaware of patient
drinking
Social factors
Medical
Comorbidities
Mental Health
Comorbidities
Medication
interactions
with alcohol
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Setting goals with the patient
Linking alcohol use to medical issues
Responding to change talk
Approach in Future Visits
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Raise alcohol
Link alcohol to medical/mental health
Use BI strategies
Use EHR tools
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5 residents (28%) used at least one EHR tool
◦ 3 charts HPI tool
◦ 2 charts A/P tool
◦ 5 charts PI tools
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Use of tools
◦ Provision of tailored resources to patients
◦ Criteria for SUD
◦ Elements of appropriate plan
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Barriers to use
◦ Unaware
◦ Not part of regular workflow
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More intensive training with opportunities for
practice and feedback may be required to
improve brief intervention skills.
Additional reinforcement including
simulation to practice integration of EHR
tools is essential to their usefulness.
CSR is a potentially useful tool to:
◦ assess curricular interventions
◦ reinforce curricular materials
◦ provide individualized feedback
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Single institution
CSR was not recorded
Dual role of faculty performing CSR
Residents identified patients for discussion
CSR used as a summative tool
1.
2.
3.
4.
5.
Bernstein E et al. An evidence based alcohol screening, brief
intervention and referral to treatment (SBIRT) curriculum for
emergency department (ED) providers improves skills and
utilization. Subst Abus. 2007;28(4):79-92.
Seale JP et al. Skills-based residency training in alcohol
screening and brief intervention: Results from the GeorgiaTexas “Improving Brief Intervention” project. Subst Abus.
2012;33(3):261-271.
Satterfield JM et al. Using Standardized Patients to Evaluate
Screening, Brief Intervention, and Referral to Treatment (SBIRT)
Knowledge and Skill Acquisition for Internal Medicine
Residents. Subst Abus. 2012 ;33 :303-307.
Wamsley MA et al. Team-Based Learning Exercise Efficiently
Teaches Brief Intervention Skills to Medicine Residents. Subst
Abus, 2013;34:344-349.
Schipper S, Ross S. Structured teaching and assessment: new
chart-stimulated recall worksheet for family medicine
residents. Can Fam Physician 2010;50:958-59.