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Michael A LaMantia,1–4 Anthony J Perkins,5,6 Sujuan Gao,2,7 Mary G Austrom,8,9 Cathy A Alder,10 Dustin D French,11,12 Debra K Litzelman,2,3,13 Ann H Cottingham,3 Malaz A Boustani1–3,5 1Indiana University Center for Aging Research, 2Regenstrief Institute, Inc., 3Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, 4Department of Medicine, University of Vermont College of Medicine, Burlington, VT, 5Indiana University Center for Health Innovation and Implementation Science, 6Indiana Clinical and Translational Sciences Institute, 7Department of Biostatistics, Indiana University School of Medicine, 8Department of Psychiatry, Indiana University School of Medicine, 9Indiana University Alzheimer’s Disease Center, 10Eskenazi Health, Indianapolis, IN, 11Department of Ophthalmology, Feinberg School of Medicine, Northwestern University, 12Veterans Affairs Health Services Research and Development Service, Chicago, IL, 13Indiana University Center for Health Services and Outcomes Research, Indianapolis, IN, USA Objective: To evaluate the effect of the Aging Brain Care (ABC) Medical Home program’s depression module on patients’ depression severity measurement over time.Design: Retrospective chart review.Setting: Public hospital system.Participants: Patients enrolled in the ABC Medical Home program between October 1, 2012 and March 31, 2014.Methods: The response of 773 enrolled patients who had multiple patient health questionnaire-9 (PHQ-9) scores recorded in the ABC Medical Home program’s depression care protocol was evaluated. Repeatedly measured PHQ-9 change scores were the dependent variables in the mixed effects models, and demographic and comorbid medical conditions were tested as potential independent variables while including random effects for time and intercept.Results: Among those patients with baseline PHQ-9 scores >10, there was a significant decrease in PHQ-9 scores over time (P50% decline from baseline) on the PHQ-9 at 6 months. Conclusion: These analyses demonstrate evidence for the sustained effectiveness of the ABC Medical Home program at inducing depression remission outcomes while employing clinical staff who required less formal training than earlier clinical trials. Keywords: geriatrics, care coordination, Medicare

In an effort to reduce 'agism' which is prevalent among medical trainees, a new geriatrics educational experience for medical students aimed at improving attitudes toward older patients was developed. Each 90-minute Older Adult Session included four components: initial reflective writing exercise; introduction to the session; 75-minute dialogue with the 'Council of Elders,' a group of active, 'well' older adults; and final reflective writing exercise. The new session was provided to 237 first- and second-year medical students during the 2006/07 academic year at Indiana University School of Medicine. Session evaluation included comparing scores on the 14-item Geriatrics Attitude Scale administered before and after the session, identifying attitude changes in the reflective writing exercises, and a student satisfaction survey. Student responses on the Geriatrics Attitude Scale after the session were significantly improved in seven of 14 items, demonstrating better attitudes toward being with and listening to older people and caring for older patients. Analysis of the reflective writings revealed changing of negative to positive or reinforced positive attitudes in 27% of medical students, with attitudes not discernable in the remaining 73% (except one student, in whom positive attitudes changed to negative). Learner satisfaction with the Older Adult Session was high, with 98% agreeing that the session had a positive effect on insight into the care of older adults. A Council of Elders coupled with a reflective writing exercise is a promising new approach to improving attitudes of medical students toward their geriatric patients. [ABSTRACT FROM AUTHOR]

Substance use disorders among reproductive aged women are a major public health issue. There is little work investigating the validity and reliability of electronic health record (EHR) data for measuring substance use in this population. This study examined the concordance of self-reported substance use with clinical diagnoses of substance use, substance abuse and substance use disorder in EHR data. Reproductive age women enrolled in the Community-Based Addiction Reduction (CARE) program were interviewed by peer recovery coaches (PRC) at enrollment. That survey data was linked with EHR data (n = 102). Concordance between self-reported substance use and clinical diagnoses in the EHR was examined for opioids, cannabis/THC, and cocaine. Cohen's kappa, sensitivity, and specificity were calculated. The survey captured a higher number of women who use substances compared to the EHR. The concordance of self-report with EHR diagnosis varied by substance and was higher for opioids (17.6%) relative to cannabis/THC (8.8%), and cocaine (3.0%). Additionally, opioids had higher sensitivity (46.2%) and lower specificity (76.2%) relative to cannabis/THC and cocaine. Survey data collected by PRCs captured more substance use than EHRs, suggesting that EHRs underestimate substance use prevalence. The higher sensitivity and lower specificity of opioids was due to a larger number of women who had a diagnosis of opioid use in the EHR who did not self-report opioid use in the self-report survey relative to cannabis/THC and cocaine. Opioid self-report and diagnosis may be influenced by research setting, question wording, or receipt of medication for opioid use disorder., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Unilateral approaches to global health innovations can be transformed into cocreative, uniquely collaborative relationships between low-income and middle-income countries (LMICs) and high-income countries (HIC), constituted as 'reciprocal innovation' (RI). Since 2018, the Indiana Clinical and Translational Sciences Institute (CTSI) and Indiana University (IU) Center for Global Health Equity have led a grants programme sculpted from the core elements of RI, a concept informed by a 30-year partnership started between IU (Indiana) and Moi University (Kenya), which leverages knowledge sharing, transformational learning and translational innovations to address shared health challenges. In this paper, we describe the evolution and implementation of an RI grants programme, as well as the challenges faced. We aim to share the successes of our RI engagement and encourage further funding opportunities to promote innovations grounded in the RI core elements. From the complex series of challenges encountered, three major lessons have been learnt: dedicating extensive time and resources to bring different settings together; establishing local linkages across investigators; and addressing longstanding inequities in global health research. We describe our efforts to address these challenges through educational materials and an online library of resources for RI projects. Using perspectives from RI investigators funded by this programme, we offer future directions resulting from our 5-year experience in applying this RI-focused approach. As the understanding and implementation of RI grow, global health investigators can share resources, knowledge and innovations that have the potential to significantly change the face of collaborative international research and address long-standing health inequities across diverse settings., Competing Interests: Competing interests: None., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Interprofessional (IP) collaboration and effective teamwork remain variable in healthcare organisations. IP bias, assumptions and conflicts limit the capacity of healthcare teams to leverage the expertise of their members to meet growing complexities of patient needs and optimise healthcare outcomes. We aimed to understand how a longitudinal faculty development programme, designed to optimise IP learning, influenced its participants in their IP roles., Design: In this qualitative study, using a constructivist grounded theory approach, we analysed participants' anonymous narrative responses to open-ended questions about specific knowledge, insights and skills acquired during our IP longitudinal faculty development programme and applications of this learning to teaching and practice., Setting: Five university-based academic health centres across the USA., Participants: IP faculty/clinician leaders from at least three different professions completed small group-based faculty development programmes over 9 months (18 sessions). Site leaders selected participants from applicants forecast as future leaders of IP collaboration and education., Interventions: Completion of a longitudinal IP faculty development programme designed to enhance leadership, teamwork, self-knowledge and communication., Results: A total of 26 programme participants provided 52 narratives for analysis. Relationships and relational learning were the overarching themes. From the underlying themes, we developed a summary of relational competencies identified at each of three learning levels: (1) Intrapersonal (within oneself): reflective capacity/self-awareness, becoming aware of biases, empathy for self and mindfulness. (2) Interpersonal (interacting with others): listening, understanding others' perspectives, appreciation and respect for colleagues and empathy for others. (3) Systems level (interacting within organisation): resilience, conflict engagement, team dynamics and utilisation of colleagues as resources., Conclusions: Our faculty development programme for IP faculty leaders at five US academic health centres achieved relational learning with attitudinal changes that can enhance collaboration with others. We observed meaningful changes in participants with decreased biases, increased self-reflection, empathy and understanding of others' perspectives and enhanced IP teamwork., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

The COVID-19 pandemic disrupted social support networks as well as resource access for participants. The purpose of this study was to: analyze the experiences of older adults enrolled in a geriatric-focused community health worker (CHW) support program, to gain a better understanding of how CHWs might enhance care delivery, and to further understand how COVID-19 affected the social and emotional needs and well-being of older adults during the first 18 months of the pandemic. Qualitative analysis was performed on notes entered by CHWs based on 793 telephone encounters with 358 participants between March 2020 and August 2021. Analysis was performed by two reviewers independently coding the data. Weighing the benefits of seeing family against the risks of COVID exposure was a source of emotional distress for participants. Our qualitative analysis suggests that CHWs were effective in providing emotional support and connecting participants to resources. CHWs are capable of bolstering the support networks of older adults and carrying out some of the responsibilities conventionally fulfilled by family supports. CHWs addressed participant needs that are frequently unmet by healthcare team members and provided emotional support to participants contributing to health and well-being. CHW assistance can fill gaps in support left by the healthcare system and family support structures.

To identify program characteristics that influence the retention of women of reproductive age in the C ommunity-based A ddiction Re duction program (CARE), mixed-method analyses of CARE survey data and CARE Peer Recovery Coach (PRC) narrative entries of participant encounters were performed. About 251 women were enrolled in this prospective community-based implementation science intervention. We compared survey responses by race for treatment status, treatment motivation scales, and retention in the program at intake, 2-, 6-, 9-, and 12-month follow ups using Chi-square/ T -tests. Qualitative analysis of PRC narrative entries was conducted following thematic analysis and crystallization immersion analytic methods. White compared with Black women in CARE were significantly more likely to be in treatment at intake ( P  < .001) and more motivated to engage in recovery treatment ( P  < .001). However, Black women were retained longer in CARE at 2- ( P  < .006), 6- ( P  < .011), and 9- ( P  < .004) months. PRC narrative entries were coded, and emergent themes mapped well to the 4 types of supports provided by PRC as outlined by the Substance Abuse and Mental Health Services Administration: emotional, instrumental, informational, and affiliational. Analysis of narrative entries by race revealed that Black women were given more detailed information, communications with PRC were more encouraging and proactive in identifying and meeting needs, and PRC took a more hands-on approach when assisting and linking to resources. The inclusion of PRC as integral members of SUD recovery programs may preferentially provide Black women with SUD the opportunity to build more trusting relationships with these peer coaches, thereby increasing their participation and retention.

The objective of this study was to increase screening for falls and dementia by improving interprofessional (IP) providers' and staffs' knowledge and attitudes toward the care of older patients and team-based care. An intervention, including education about screening and an electronic health record (EHR) flowsheet, was rolled-out across eight Federally Qualified Health Centers (FQHC). Participants were 262 IP health providers who served 6670 patients ≥ age 65 > age 65 . An EHR flowsheet with two-item screeners for falls and dementia triggered automatically for patients ≥ age 65. Documentation of screening for falls and dementia was abstracted from the EHR for the year prior to and the year after the interventions began. Baseline screening rates for falls and dementia were flat; from the start of education intervention until EHR live date, screening rates increased significantly; after EHR live date, the screening rates continued increasing significantly. A combined education-system intervention can improve screening for falls and dementia in FQHC.

Global health researchers often discount mutual learning and benefit to address shared health challenges across high and low- and middle-income settings. Drawing from a 30-year partnership called AMPATH that started between Indiana University in the US and Moi University in Kenya, we describe an innovative approach and program for mutual learning and benefit coined 'reciprocal innovation.' Reciprocal innovation harnesses a bidirectional, co-constituted, and iterative exchange of ideas, resources, and innovations to address shared health challenges across diverse global settings. The success of AMPATH in Kenya, particularly in HIV/AIDS and community health, resulted in several innovations being 'brought back' to the US. To promote the bidirectional flow of learning and innovations, the Indiana CTSI reciprocal innovation program hosts annual meetings of multinational researchers and practitioners to identify shared health challenges, supports pilot grants for projects with reciprocal exchange and benefit, and produces educational and training materials for investigators. The transformative power of global health to address systemic health inequities embraces equitable and reciprocal partnerships with mutual benefit across countries and communities of academics, practitioners, and policymakers. Leveraging a long-standing partnership, the Indiana CTSI has built a reciprocal innovation program with promise to redefine global health for shared wellbeing at a global scale.

Background: The care of older adults with complex medical conditions requires effective team-based care., Problem: Nursing and social work students need a curriculum that provides them with immersive experiences in geriatrics to prepare them for competent practice., Approach: This Geriatric Workforce Enhancement Program supported 5 advanced practice nursing (APN) and 5 master of social work (MSW) student fellows in a 2-semester program, with 3 cohorts completing the fellowship over 3 years (N = 30)., Outcomes: By the completion of the fellowship, students had (1) demonstrated increased knowledge of age-related changes and health problems experienced by older adults, (2) developed clinical competencies in providing patient-centered health care for older adults, and (3) assessed the fellowship as helpful in preparing for interprofessional team care., Conclusions: An interprofessional gerontology fellowship for APN and MSW students can develop knowledge and skills in team-based care for older adults. Recommendations for creating a fellowship curriculum are provided., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Health outcomes for complex older adults are enhanced by interprofessional collaboration. Funded by a Geriatrics Workforce Enhancement Program (GWEP), an interprofessional team of educators developed a short-term geriatrics experience, including four hours of pre-clinical education and 12-20 hours of immersion in team-based care for advanced learners in nursing (n = 70 APN), social work (n = 48 MSW), and medicine (n = 122 medical students). Content focused on five areas: medication management, dementia, depression, falls, and myths about aging. Learners completed pre/post surveys measuring knowledge of geriatrics, attitudes toward geriatric patients and team care, and post-surveys regarding perceptions of the overall clinical experience. Results showed significant improvement in knowledge and attitudes toward older adults and interprofessional (IP) team practice. Qualitative comments reflected increased empathy toward and enthusiasm for working with older adults, valuing IP teams, and a desire for geriatrics content earlier in their respective curricula.

The purpose of the program WeCare was to provide a personalized approach to addressing the wide array of psycho-social-cultural-fiscal needs to reduce risk factors for infant mortality (IM) by supporting maternal and infant health through health coaching by community health workers (CHWs). A prospective cohort study of 1,513 women from highest risk ZIP codes for IM in central Indiana were followed over three years. The WeCare program focused on training and deploying CHWs to provide evidence-based, patient-centered social care and support to pregnant and postpartum women and tracked outcomes in health risk categories (mental health, nutrition, safe sleep, breastfeeding) targeted for behavioral change. The low birth weight rate among program participants was lower (8.9%) than Marion County's rate (10%) (p=0.23) with statistically significant improvement in many risk behaviors. Despite limitations, the personalized coaching provided by the CHWs provided an effective, practical approach to maternal and child health disparities.

Background: Community health workers (CHWs) can increase access to various primary healthcare services; however, their potential for improving surgical care is under-explored. We sought to assess the role of CHWs in the surgical cascade, defined as disease screening, linkage to operative care, and post-operative care. Given the well-described literature on CHWs and screening, we focused on the latter two steps of the surgical cascade., Methods: We conducted a scoping review of the peer-reviewed literature. We searched for studies published in any language from January 1, 2000 to May 1, 2020 using electronic literature databases including Pubmed/MEDLINE, Web of Science, SCOPUS, and Google Scholar. We included articles on CHW involvement in linkage to operative care and/or post-operative surgical care. Narrative and descriptive methods were used to analyze the data., Results: The initial search identified 145 articles relevant to steps in the surgical cascade. Ten studies met our inclusion criteria and were included for review. In linkage to care, CHWs helped increase surgical enrollment, provide resources for vulnerable patients, and build trust in healthcare services. Post-operatively, CHWs acted as effective monitors for surgical-site infections and provided socially isolated patients with support and linkage to additional services. The complex and wide-ranging needs of surgical patients illustrated the need to view surgical care as a continuum rather than a singular operative event., Conclusion: While the current literature is limited, CHWs were able to maneuver complex medical, cultural, and social barriers to surgical care by linking patients to counseling, education, and community resources, as well as post-operative infection prevention services. Future studies would benefit from more rigorous study designs and larger sample sizes to further elucidate the role CHWs can serve in the surgical cascade., (© 2021. The Author(s).)

Introduction: As use of electronic medical records (EMRs) increases in healthcare, multiple accreditation organizations recommend training future clinicians on EMRs as part of the academic curriculum. Therefore, some pharmacy programs now utilize an academic EMR. Our objective was to examine pharmacy instructors' early experiences with a commercially available teaching EMR (tEMR) in order to identify current and future priorities along with benefits and barriers to academic EMR use in pharmacy education., Methods: We conducted semi-structured interviews and a web-based survey with pharmacy instructors. Interview and survey data analyses consisted of hybrid inductive/deductive approaches to coding data and descriptive statistics, respectively. We mapped themes to the Pharmacists' Patient Care Process (PPCP)., Results: Seven instructors participated in interviews, and 10 completed the survey. We identified 25 interview themes that were generally congruent with survey responses. A noted benefit of the tEMR was providing a large repository of real-life patient data. Instructors' current priorities for tEMR activities primarily aligned with "collect," "assess," and "plan" steps of the PPCP. One reported barrier was insufficient training regarding the tEMR capabilities. Instructors offered innovative ideas for future academic EMR use, including pharmacokinetics, incident reporting, and longitudinal cases., Conclusions: Study findings are most applicable to pharmacy programs in the early stages of academic EMR adoption. We identified opportunities for pharmacy programs to facilitate innovative, future use of academic EMRs, including curriculum planning, so pharmacy students gain experience using EMR functions for each PPCP step and develop more advanced EMR skills., Competing Interests: Declaration of Competing Interest None., (Copyright © 2021 Elsevier Inc. All rights reserved.)

The objective of this study is to provide an overview of the Regenstrief Teaching Electronic Medical Record (tEMR), how the tEMR could be used, and how it is currently being used in health professions education. The tEMR is a derivative of a real-world electronic health record (EHR), a large, pseudonymized patient database, and a population health tool designed to support curricular goals. The tEMR has been successfully adopted at 12 health professional, public health, and health information technology (HIT) schools, with over 11 800 unique student users and more than 74 000 logins, for case presentation, to develop diagnostic and therapeutic plans, and to practice documentation skills. With the exponential growth of health-related data and the impact of HIT on work-life balance, it is critical for students to get early EHR skills practice and understand how EHR's work. The tEMR is a promising, scalable, flexible application to help health professional students learn about common HIT tools and issues., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Medical Informatics Association.)

Older adults are vulnerable to risks associated with medications. This study explores the roles of Social Workers in facilitating medication safety for older adults. Eight social workers from federally qualified health centers participated in a case-based and interactive medication safety curriculum. They participated in an in-depth, semi-structured interview to explore their roles and strategies in assisting older adults and caregivers with medication management. Findings were transcribed and analyzed. Six themes characterizing social workers' roles in medication management were identified: a) Referral: matching patients and medication-related resources within the health-care system and community; b) Communication: connecting providers, patients, caregivers, and support system; c) Access to medicine: addressing unique needs of each patient to foster their ability to obtain their medicines; d) Social Determinants of Health: investigating the social challenges of each patient and facilitating specific medication management approaches to meet identified needs; e) Engagement: engaging patients in co-developing a treatment plan; f) Caregiver Support: preparing caregivers to assist in medication management. Social workers are trained and well positioned to provide a multi-faceted approach to improve medication management for older adults. Their unique perspectives and skills are important in addressing the complex challenges of medication management.

As interest in global health education continues to increase, residency programs seeking to accommodate learners' expectations for global health learning opportunities often face challenges providing high-quality global health training. To address these challenges, some residency programs collaborate across medical specialties to create interdisciplinary global health residency tracks or collaborative interdisciplinary global health tracks (CIGHTs). In this Perspective, the authors highlight the unique aspects of interdisciplinary tracks that may benefit residency programs by describing 3 established U.S.-based programs as models: those at Indiana University, Mount Sinai Hospital, and the University of Virginia. Through collaboration and economies of scale, CIGHTs are able to address some of the primary challenges inherent to traditional global health tracks: lack of institutional faculty support and resources, the need to develop a global health curriculum, a paucity of safe and mentored international rotations, and inconsistent resident interest. Additionally, most published global health learning objectives and competencies (e.g., ethics of global health work, predeparture training) are not discipline specific and can therefore be addressed across departments-which, in turn, adds to the feasibility of CIGHTs. Beyond simply sharing the administrative burden, however, the interdisciplinary learning central to CIGHTs provides opportunities for trainees to gain new perspectives in approaching global health not typically afforded in traditional global health track models. Residency program leaders looking to implement or modify their global health education offerings, particularly those with limited institutional support, might consider developing a CIGHT as an approach that leverages economies of scale and provides new opportunities for collaboration.

Objective: To explore leadership perspectives on how to maintain high quality efficient care that is also person-centered and humanistic., Methods: The authors interviewed and collected narrative transcripts from a convenience sample of 32 institutional healthcare leaders at seven U.S. medical schools. The institutional leaders were asked to identify factors that either promoted or inhibited humanistic practice. A subset of authors used the constant comparative method to perform qualitative analysis of the interview transcripts. They reached thematic saturation by consensus on the major themes and illustrative examples after six conference calls., Results: Institutional healthcare leaders supported vision statements, policies, organized educational and faculty development programs, role modeling including their own, and recognition of informal acts of kindness to promote and maintain humanistic patient-care. These measures were described individually rather than as components of a coordinated plan. Few healthcare leaders mentioned plans for organizational or systems changes to promote humanistic clinician-patient relationships., Conclusions: Institutional leaders assisted clinicians in dealing with stressful practices in beneficial ways but fell short of envisaging systems approaches that improve practice organization to encourage humanistic care., Practice Implications: To preserve humanistic care requires system changes as well as programs to enhance skills and foster humanistic values and attitudes., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: Changes in the organization of medical practice have impeded humanistic practice and resulted in widespread physician burnout and dissatisfaction., Objective: To identify organizational factors that promote or inhibit humanistic practice of medicine by faculty physicians., Design: From January 1, 2015, through December 31, 2016, faculty from eight US medical schools were asked to write reflectively on two open-ended questions regarding institutional-level motivators and impediments to humanistic practice and teaching within their organizations., Participants: Sixty eight of the 92 (74%) study participants who received the survey provided written responses. All subjects who were sent the survey had participated in a year-long small-group faculty development program to enhance humanistic practice and teaching. As humanistic leaders, subjects should have insights into motivating and inhibiting factors., Approach: Participants' responses were analyzed using the constant comparative method., Key Results: Motivators included an organizational culture that enhances humanism, which we judged to be the overarching theme. Related themes included leadership supportive of humanistic practice, responsibility to role model humanism, organized activities that promote humanism, and practice structures that facilitate humanism. Impediments included top down organizational culture that inhibits humanism, along with related themes of non-supportive leadership, time and bureaucratic pressures, and non-facilitative practice structures., Conclusions: While healthcare has evolved rapidly, efforts to counteract the negative effects of changes in organizational and practice environments have largely focused on cultivating humanistic attributes in individuals. Our findings suggest that change at the organizational level is at least equally important. Physicians in our study described the characteristics of an organizational culture that supports and embraces humanism. We offer suggestions for organizational change that keep humanistic and compassionate patient care as its central focus.

Objective: Major reorganizations of medical practice today challenge physicians' ability to deliver compassionate care. We sought to understand how physicians who completed an intensive faculty development program in medical humanism sustain their humanistic practices., Methods: Program completers from 8 U.S. medical schools wrote reflections in answer to two open-ended questions addressing their personal motivations and the barriers that impeded their humanistic practice and teaching. Reflections were qualitatively analyzed using the constant comparative method., Results: Sixty-eight physicians (74% response rate) submitted reflections. Motivating factors included: 1) identification with humanistic values; 2) providing care that they or their family would want; 3) connecting to patients; 4) passing on values through role modelling; 5) being in the moment. Inhibiting factors included: 1) time, 2) stress, 3) culture, and 4) episodic burnout., Conclusions: Determination to live by one's values, embedded within a strong professional identity, allowed study participants to alleviate, but not resolve, the barriers. Collaborative action to address organizational impediments was endorsed but found to be lacking., Practice Implications: Fostering fully mature professional development among physicians will require new skills and opportunities that reinforce time-honored values while simultaneously partnering with others to nurture, sustain and improve patient care by addressing system issues., (Copyright © 2017 Elsevier B.V. All rights reserved.)

The authors describe the first 11 academic years (2005-2006 through 2016-2017) of a longitudinal, small-group faculty development program for strengthening humanistic teaching and role modeling at 30 U.S. and Canadian medical schools that continues today. During the yearlong program, small groups of participating faculty met twice monthly with a local facilitator for exercises in humanistic teaching, role modeling, and related topics that combined narrative reflection with skills training using experiential learning techniques. The program focused on the professional development of its participants. Thirty schools participated; 993 faculty, including some residents, completed the program.In evaluations, participating faculty at 13 of the schools scored significantly more positively as rated by learners on all dimensions of medical humanism than did matched controls. Qualitative analyses from several cohorts suggest many participants had progressed to more advanced stages of professional identity formation after completing the program. Strong engagement and attendance by faculty participants as well as the multimodal evaluation suggest that the program may serve as a model for others. Recently, most schools adopting the program have offered the curriculum annually to two or more groups of faculty participants to create sufficient numbers of trained faculty to positively influence humanistic teaching at the institution.The authors discuss the program's learning theory, outline its curriculum, reflect on the program's accomplishments and plans for the future, and state how faculty trained in such programs could lead institutional initiatives and foster positive change in humanistic professional development at all levels of medical education.

Community health workers (CHWs) can engage elderly persons in advance care planning (ACP) conversations. We report how trained CHWs used Go Wish cards (GW R cards) to identify patients' highest priority preferences and evaluated whether engaging in ACP conversations was associated with subsequent health care utilization. A one-year long, pre-post longitudinal design was used to evaluate our educational intervention using mixed-methods. 392 patients (mean of 73.3 years, 82% women, 48% African American, 43% Caucasian) enrolled in the Aging Brain Care (ABC) program and participated in ACP discussions with CHWs. We expanded the role of the ABC's CHW, who work directly with individuals and caregivers during home visits to monitor bio-psycho-social needs, to include ACP conversations. The CHWs received ACP training, practice with tools such as GW R cards, and support from an electronic health record (EHR) clinical decision support tool. Quantitative measures of patients' ACP preferences and health care utilization were abstracted from the EHR. Qualitative data about patients' perceptions of CHWs in facilitating ACP discussions was obtained through semi-structured interviews. Eighty-six patients' data indicated that they had engaged in a preferences-for-care process using GW R cards. The top-three card choices by patients was attending to spirituality and religious concerns, preparing for end of life, and maintaining personal wholeness. CHWs were able to effectively engage in ACP conversations with patients and GW R cards were a positive way to stimulate discussion of issues previously undiscussed.

Background: Globalization has increased the demand for international experiences in medical education. International experiences improve medical knowledge, clinical skills, and self-development; influence career objectives; and provide insights on ethical and societal issues. However, global health rotations can end up being no more than tourism if not structured to foster personal transformation and global citizenship., Objective: We conducted a qualitative assessment of trainee-reported critical incidents to more deeply understand the impact of our global health experience on trainees., Methods: A cross-sectional survey was administered to trainees who had participated in a 2-month elective in Kenya from January 1989 to May 2013. We report the results of a qualitative assessment of the critical incident reflections participants (n = 137) entered in response to the prompt, "Write about one of your most memorable experiences and explain why you chose to describe this particular one." Qualitative analyses were conducted using thematic analysis and crystallization immersion analytic methods based on the principles of grounded theory, employing a constructivists' research paradigm., Findings: Four major themes emerged. These themes were Opening Oneself to a Broader World View; Impact of Suffering and Death; Life-Changing Experiences; and Commitment to Care for the Medically Underserved., Conclusions: Circumstances that learners encounter in the resource-scarce environment in Kenya are eye-opening and life-changing. When exposed to these frame-shifting circumstances, students elaborate on or transform existing points of view. These emotionally disruptive experiences in an international health setting allowed students to enter a transformational learning process with a global mind. Students can see the world as an interdependent society and develop the capacity to advance both their enlightened self-interest and the interest of people elsewhere in the world as they mature as global citizens. Medical schools are encouraged to foster these experiences by finding ways to integrate them into curriculum., (Copyright © 2017 Icahn School of Medicine at Mount Sinai. Published by Elsevier Inc. All rights reserved.)

Background: Advance care planning (ACP) is recommended for all persons to ensure that the care they receive aligns with their values and preferences., Objective: To evaluate an ACP intervention developed to better meet the needs and priorities of persons with chronic diseases, including mild cognitive impairment., Research Design: A year-long, pre-post intervention using lay community health workers [care coordinator assistants (CCAs)] trained to conduct and document ACP conversations with patients during home health visits with pre-post evaluation., Subjects: The 818 patients were 74.2 years old (mean); 78% women; 51% African American; 43% white., Measures: Documentation of ACP conversation in electronic health record fields and health care utilization outcomes., Results: In this target population ACP documentation rose from 3.4% (pre-CCA training) to 47.9% (post) of patients who had at least 1 discussion about ACP in the electronic health record. In the 1-year preintervention period, there were no differences in admissions, emergency department (ED) visits, and outpatient visits between patients who did and did not have ACP discussion. After adjusting for prior hospitalization and ED use histories, ACP discussions were associated with a 34% less probability of hospitalization (hazard ratios, 0.66; 95% confidence interval, 0.45-0.97), and similar effects are apparent on ED use independent of age and prior ED use effects., Conclusions: Patients with chronic diseases including mild cognitive impairment can engage in ACP conversations with trusted home health care providers. Having ACP conversation is associated with significant reduction in seeking urgent health care and in hospitalizations.

This pilot study was designed to measure teamwork and the relationship of teamwork to patient perceptions of care among 63 members of 12 oncology teams at a Cancer Centre in the Midwest. Lack of teamwork in cancer care can result in serious clinical errors, fragmentation of care, and poor quality of care. Many oncology team members, highly skilled in clinical care, are not trained to work effectively as members of a care team. The research team administered the Relational Coordination survey to core oncology team members-medical oncologists, nurse coordinators, and clinical secretaries-to measure seven dimensions of team skills (four relating to communication [frequency, timeliness, accuracy, and problem solving] and three relating to relationship [shared goals, shared knowledge, and mutual respect]) averaged to create a Relational Coordination Index. The results indicated that among the team member roles, nurse coordinator relational coordination indices were the strongest and most positively correlated with patient perception of care. Statistically significant correlations were intra-nurse coordinator relational coordination indices and two patient perception of care factors (information and education and patient's preferences). All other nurse coordinator intra-role as well as inter-role correlations were also positively correlated, although not statistically significant.

Objective: Although patients want to participate in discussions and decisions about their end-of-life care, studies show that providers frequently fail to invite them to explore advanced care preferences or goals for living. The purpose of our demonstration project was to provide education and coaching to individuals, health providers, and organizations across the state of Indiana intended to facilitate these conversations, documenting and honoring individuals' life goals and preferences for care during the final stages of life., Method: Education and training engaged community members as well as healthcare providers to: (1) improve participant comfort and facility discussing end-of-life issues; (2) improve knowledge of healthcare choices, including palliative and hospice care; and (3) prepare all participants to explore and document personal values, life goals, and priorities as well as goals of care., Results: Between January of 2013 and June of 2015, the team educated close to 5,000 participants. Participants' ratings of the quality and perceived usefulness of the educational events ranged from 4 to 5 (using a 5-point scale, with 5 = most effective). Participant comments were overwhelmingly favorable and indicated an intention to put the advance care planning resources, communication skills, knowledge of palliative and hospice care, and personal renewal techniques into practice., Significance of Results: Participant motivation to foster advance care planning, discussions of palliative care, and end-of-life conversations was facilitated by the reframing of these conversations as identifying goals of care and priorities for living well during an important stage of life. Successful strategies included helping providers and patients to adopt a broader meaning for "sustaining hope" (not for cure, but for engaging in highly valued activities), developing provider communication skills and comfort in initiating potentially difficult discussions, engaging a new community health workforce who will develop trusting relationships with patients in home-based services, and fostering self-awareness and self-care among palliative care providers.

Purpose: Behavioral and social science (BSS) competencies are needed to provide quality health care, but psychometrically validated measures to assess these competencies are difficult to find. Moreover, they have not been mapped to existing frameworks, like those from the Liaison Committee on Medical Education (LCME) and Accreditation Council for Graduate Medical Education (ACGME). This systematic review aimed to identify and evaluate the quality of assessment tools used to measure BSS competencies., Method: The authors searched the literature published between January 2002 and March 2014 for articles reporting psychometric or other validity/reliability testing, using OVID, CINAHL, PubMed, ERIC, Research and Development Resource Base, SOCIOFILE, and PsycINFO. They reviewed 5,104 potentially relevant titles and abstracts. To guide their review, they mapped BSS competencies to existing LCME and ACGME frameworks. The final included articles fell into three categories: instrument development, which were of the highest quality; educational research, which were of the second highest quality; and curriculum evaluation, which were of lower quality., Results: Of the 114 included articles, 33 (29%) yielded strong evidence supporting tools to assess communication skills, cultural competence, empathy/compassion, behavioral health counseling, professionalism, and teamwork. Sixty-two (54%) articles yielded moderate evidence and 19 (17%) weak evidence. Articles mapped to all LCME standards and ACGME core competencies; the most common was communication skills., Conclusions: These findings serve as a valuable resource for medical educators and researchers. More rigorous measurement validation and testing and more robust study designs are needed to understand how educational strategies contribute to BSS competency development.

Background: Global health experiences evoke a profound awareness of cultural differences, inspire learners to prioritize professional values, and provide a lens for addressing global health care challenges. This study compares the long-term career and practice choices of participants in a 2-month Indiana University-Moi University, Kenya elective from 1989-2013 with those of a control group., Methods: Global health elective (GHE) participants and a random sample of alumni without GHE experience were surveyed on their clinical practice, public health and global health activities., Results: Responses from 176 former participants were compared with a control group of 177 alumni. GHE participants were more likely than similar controls to provide care to underserved U.S. populations (p=0.037), spend time in global health, public health, and public policy activities (p=0.005) and be involved in global health advocacy (p=0.001). Using multivariable analysis, GHE participants were more likely to be generalists (p<0.05), report that healthcare costs influenced medical decision-making (p<0.05), and provide healthcare outside the U.S. for ≥1 week/year (p<0.001)., Conclusions: Many years out of training, GHE participants were more likely to be generalists working with underserved populations, to be cost-conscious in their healthcare decision-making, and to be involved in global health, public health or public policy., Implications: With the primary care provider shortage and need for greater awareness among providers of healthcare costs, our study shows that that global health experiences may yield broader benefits to the U.S. medical system., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: The Communication, Curriculum, and Culture (C3) instrument is a well-established survey for measuring the professional learning climate or hidden curriculum in the clinical years of medical school. However, few instruments exist for assessing professionalism in the pre-clinical years. We adapted the C3 instrument and assessed its utility during the pre-clinical years at two U.S. medical schools., Methods: The ten-item Pre-Clinical C3 survey was adapted from the C3 instrument. Surveys were administered at the conclusion of the first and second years of medical school using a repeated cross-sectional design. Factor analysis was performed and Cronbach's alphas were calculated for emerging dimensions., Results: The authors collected 458 and 564 surveys at two medical schools during AY06-07 and AY07-09 years, respectively. Factor analysis of the survey data revealed nine items in three dimensions: "Patients as Objects", "Talking Respectfully of Colleagues", and "Patient-Centered Behaviors". Reliability measures (Cronbach's alpha) for the Pre-Clinical C3 survey data were similar to those of the C3 survey for comparable dimensions for each school. Gender analysis revealed significant differences in all three dimensions., Conclusions: The Pre-Clinical C3 instrument's performance was similar to the C3 instrument in measuring dimensions of professionalism. As medical education moves toward earlier and more frequent clinical and inter-professional educational experiences, the Pre-Clinical C3 instrument may be especially useful in evaluating the impact of curricular revisions.

The United States has a significant shortage of trained geriatricians and of nurses, social workers, and paraprofessionals educated to care for elderly adults. As the aging population continues to grow, providing high-quality care will require new models that better address the many needs of aging individuals and their caregivers, using cost-effective strategies. Responding to this need, the Indiana University Center for Aging Research implementation scientists developed, tested, and are now scaling up a successful collaborative care coordination model for older adults with dementia, depression, or both: the Aging Brain Care program. This model now includes a newly created frontline care provider position, the Care Coordinator Assistant. The Care Coordinator Assistant works with individuals and caregivers to monitor biopsychosocial needs and deliver evidence-based and individualized care protocols, with close supervision from the registered nurse Care Coordinator. Recognizing that current hiring practices for frontline providers were insufficient to screen for critical abilities expected in this new position, including the ability to express "caring" and empathy, a new screening process was created building on the Multiple Mini Interview (MMI) format. The Care Coordinator Assistant MMI comprised six stations, each created to simulate challenging scenarios that will be frequently encountered and to assess important candidate abilities. Overall, the six-station MMI, with two to three items per station, provided factorially valid measures and good predictive ability. The process did not appear to be overly burdensome for candidates, and interviewers noted that it was helpful in discriminating between candidates., (© 2014, Copyright the Authors Journal compilation © 2014, The American Geriatrics Society.)

Background: Global health programs that allow international experiences for US learners should also enable reciprocal learning experiences for international learners, particularly if that is a need identified by the partner institution., Methods: A partnership between Indiana University and Moi University, Kenya, has successfully hosted 41 visiting Kenyan internal medicine and pediatrics registrars at Indiana University since 2006. The program's logistics, curriculum, and evaluation are described., Results: The registrars rotated through nephrology, cardiology, hematology and oncology, infectious diseases, and intensive care, as well as related ambulatory experiences, functioning on a level comparable to fourth-year medical students. They showed significant improvement in pretest and posttest scores on a standardized National Board of Medical Examiners examination (P  =  .048). International learners experienced culture shock, yet they felt the Indiana University elective was helpful and would recommend it to future participants., Conclusions: Global health programs can reciprocate the benefits derived for US students and residents by offering learning experiences to international learners if that is an expressed need from the international partner. Barriers to those experiences can be overcome, and the hands-on, elective experience has the potential to positively affect the knowledge and attitudes of participants as well as the home nation.

Although Web-based instruction offers an advantageous approach to medical education, few studies have addressed the use of Web-based education to teach clinical content at the postgraduate level. Even fewer studies have addressed clinical outcomes after the Web-based instruction, yet postgraduate training requirements now focus on outcomes of training. A randomized trial was conducted to compare knowledge of postgraduate year (PGY) 1 residents after Web-based with that after paper-based instruction and to compare residents' clinical application of their instruction using unannounced standardized patients (SPs) and unannounced activated standardized patients (ASPs). PGY 1 residents were assigned to a month-long ambulatory rotation during which they were randomized as a block to Web- or paper-based instruction covering the same four geriatric syndromes (dementia, depression, falls, and urinary incontinence). Outcome measures were mean change scores for before and after testing and scores from SP and ASP clinical encounter forms (checklist, chart abstraction, and electronic order entry). Residents who completed the Web-based instruction showed significantly greater improvement on the knowledge tests than those who received paper-based instruction. There were no significant differences in the scores from the SP and ASP clinical encounters except that the chart abstraction score was better for Web-based group than the paper-based group for dementia. Web-based instruction is an educational tool that medical residents readily accept and can be used to improve knowledge of core geriatrics content as measured using immediate posttesting. More-intensive educational interventions are needed to improve clinical performance by trainees in the care of older patients.

Background: Calls for organizational culture change are audible in many health care discourses today, including those focused on medical education, patient safety, service quality, and translational research. In spite of many efforts, traditional "top-down" approaches to changing culture and relational patterns in organizations often disappoint., Objective: In an effort to better align our informal curriculum with our formal competency-based curriculum, Indiana University School of Medicine (IUSM) initiated a school-wide culture change project using an alternative, participatory approach that built on the interests, strengths, and values of IUSM individuals and microsystems., Approach: Employing a strategy of "emergent design," we began by gathering and presenting stories of IUSM's culture at its best to foster mindfulness of positive relational patterns already present in the IUSM environment. We then tracked and supported new initiatives stimulated by dissemination of the stories., Results: The vision of a new IUSM culture combined with the initial narrative intervention have prompted significant unanticipated shifts in ordinary activities and behavior, including a redesigned admissions process, new relational practices at faculty meetings, student-initiated publications, and modifications of major administrative projects such as department chair performance reviews and mission-based management. Students' satisfaction with their educational experience rose sharply from historical patterns, and reflective narratives describe significant changes in the work and learning environment., Conclusions: This case study of emergent change in a medical school's informal curriculum illustrates the efficacy of novel approaches to organizational development. Large-scale change can be promoted with an emergent, non-prescriptive strategy, an appreciative perspective, and focused and sustained attention to everyday relational patterns.

There is growing recognition in the medical community that being a good doctor requires more than strong scientific knowledge and excellent clinical skills. Many key qualities are essential to providing comprehensive care, including the abilities to communicate effectively with patients and colleagues, act in a professional manner, cultivate an awareness of one's own values and prejudices, and provide care with an understanding of the cultural and spiritual dimensions of patients' lives. To ensure that Indiana University School of Medicine (IUSM) graduates demonstrate this range of abilities, IUSM has undertaken a substantial transformation of both its formal curriculum and learning environment (informal curriculum). The authors provide an overview of IUSM's two-part initiative to develop and implement a competency-based formal curriculum that requires students to demonstrate proficiency in nine core competencies and to create simultaneously an informal curriculum that models and supports the moral, professional, and humane values expressed in the formal curriculum. The authors describe the institutional and curricular transformations that have enabled and furthered the new IUSM curricular goals: changes in education administration; education implementation, assessment, and curricular design; admissions procedures; performance tracking; and the development of an electronic infrastructure to facilitate the expanded curriculum. The authors address the cost of reform and the results of two progress reviews. Specific case examples illustrate the interweaving of the formal competency curriculum through the students' four years of training, as well as techniques that are being used to positively influence the IUSM informal curriculum.

The social environment or "informal" curriculum of a medical school profoundly influences students' values and professional identities. The Indiana University School of Medicine is seeking to foster a social environment that consistently embodies and reinforces the values of its formal competency-based curriculum. Using an appreciative narrative-based approach, we have been encouraging students, residents, and faculty to be more mindful of relationship dynamics throughout the school. As participants discover how much relational capacity already exists and how widespread is the desire for a more collaborative environment, their perceptions of the school seem to shift, evoking behavior change and hopeful expectations for the future.

Purpose: To validate the University of Michigan Global Rating Scale (GRS), a single-item, five-point global measure of faculty members' clinical teaching performances previously shown to be reliable., Method: In June 1998, 98 senior medical residents (98% of seniors) from four academic institutions completed the GRS for all teaching faculty at their institutions. Each resident also completed the 26-item Stanford Faculty Development questionnaire (SFDP26) for ten faculty with whom he or she had had teaching contact during residency. The SFDP26 is a validated instrument that measures seven specific aspects of clinical teaching (e.g., communication of goals, feedback)., Results: The mean GRS score (SE) was 3.83 (.07). There was no difference in mean GRS or SFDP26 subscale scores across institutions. In a random-effects model that controlled for interrater reliability, correlation coefficients comparing the mean GRS scores and the mean scores for the individual SFDP26 subscales ranged from.86 to.98., Conclusions: The GRS correlates highly with measures of seven specific aspects of teaching effectiveness among senior medical residents. The GRS is a simple, readily administered measure of faculty's teaching performances that can be used by residency programs as part of an incentive or reward program, to identify teachers as potential candidates for faculty development, or for consideration in promotion decisions.