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Background: Smoking remains the leading cause of preventable death, yet physicians inconsistently provide best-practices cessation advice to smokers. Point-of-care digital health tools can prompt and assist physicians to provide improved smoking cessation counseling. QuitAdvisorMD is a comprehensive web-based counseling and management digital health tool designed to guide smoking cessation counseling at the point-of-care. The tool enables clinicians to assess patient readiness to change and then deliver stage-appropriate interventions, while also incorporating Motivational Interviewing techniques. We present the research protocol to assess the efficacy of QuitAdvisorMD to change frequency and quality of smoking cessation counseling and its effect on patient quit rates. Methods: A practice-based, clustered, randomized controlled trial will be used to evaluate QuitAdvisorMD. Cluster design will be used where patients are clustered within primary care practices and practices will be randomized to either the intervention (QuitAdvisorMD) or control group. The primary outcome is frequency and quality of clinician initiated smoking cessation counseling. Secondary outcomes include, 1) changes in physician knowledge, skills and perceived self-efficacy in providing appropriate stage-based smoking cessation counseling and 2) patient quit attempts. Analyses will be conducted to determine pre- and post-test individual clinician outcomes and between intervention and control group practices for patient outcomes. Conclusion: Results from this study will provide important insights regarding the ability of an integrated, web-based counseling and management tool (QuitAdvisorMD) to impact both the quality and efficacy of smoking cessation counseling in primary care settings.

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The stresses of medical training can lead to burnout and other adverse outcomes. The Flourish curriculum was designed to mitigate negative effects of stress among clerkship students through debriefing and skills-building activities that foster practical wisdom: mindfulness, appreciative practice, story-telling/listening, and reflection. Students rated the curriculum highly, felt it addressed common concerns about clerkships, and were able to apply techniques from the curriculum to their clinical work. This framework can help students process their experiences and benefit from peer support, mentorship, and reflection. Fostering medical students' wisdom capacities for reflection and compassion may be protective against burnout during their training. Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-022-01522-z.

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OBJECTIVE: Emergency medical service (EMS) providers are systematically subjected to intense stimuli in their work that may result in distress and emotional suffering. While it is known that mindfulness-based stress reduction (MBSR) helps to foster well-being in healthcare workers, the effectiveness of MBSR among EMS providers is less understood. We explored the impact of a modified version of MBSR for healthcare workers called Mindfulness for Healthcare Providers (MHP) on reducing distress and promoting wellbeing in EMS providers. METHODS: A one-arm pilot study was conducted. We implemented eight two-and-a-half hour sessions of Mindfulness for Healthcare Providers with an additional day-long retreat at the end. Feasibility, perceived stress, professional quality of life, and trait mindfulness were assessed prior to and after the intervention. The professional quality of life scale includes measures of compassion satisfaction, burnout, and secondary trauma. RESULTS: Fifteen veteran EMS providers enrolled in the course; four participants dropped out. Prior to initiation of the study, no significant differences were revealed between those who did not participate (n = 48) and those who did (n = 11). After the intervention EMS providers endorsed statistically significant increases in compassion satisfaction, trait mindfulness, and decreases in burnout compared to the beginning of the program. These changes were sustained at six months post-completion. No significant changes over time were found for secondary trauma or perceived stress. CONCLUSIONS: To our knowledge, this study is the first to employ Mindfulness for Healthcare Providers in an EMS population and to demonstrate a positive impact on self-reported compassion, trait mindfulness, and burnout in this population. Additional research regarding mindfulness training within EMS populations should be conducted to further understand the relationship between mindfulness and perceived stress over time.

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BACKGROUND: Physician behaviors that undermine a culture of safety have gained increasing attention as health-care organizations strive to create a culture of safety and reduce medical errors. We developed, implemented, and assessed a course to teach physicians skills regarding effective coping and interpersonal communication skills and present our results regarding outcomes. METHODS: We examined a professional development program specifically designed to address unprofessional or distressed behaviors of physicians, and we evaluated the impact on burnout, quality of life, and emotional flooding scores of the physicians. Assessments of burnout, quality of life, and emotional flooding were assessed preintervention and postintervention. RESULTS: Results demonstrated statistically significant reductions over time in physicians' emotional flooding and emotional exhaustion (EE). Specifically, using a Wilcoxon Signed-Rank test, results revealed that flooding scores at follow-up were statistically significantly lower than at baseline, V = 590, p < 0.05, and EE and personal accomplishment distributions were found to significantly deviate from normal as indicated by Shapiro-Wilks tests (p < 0.05). A Wilcoxon signed-rank test indicated that EE scores were significantly higher at baseline compared to follow-up 1, V = 285, p < 0.05. CONCLUSION: We conclude that the physician participants who enrolled in the educational skills training program improved scores on emotional flooding and EE and that this may be indicative of improved skills related to their experiences and learning in the program. These improved skills in physicians may have a positive impact on the overall culture of safety in the health system setting.

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PURPOSE: Primary care practices are an ideal setting for reducing national smoking rates because >70% of smokers visit their physician annually, yet smoking cessation counseling is inconsistently delivered to patients. We designed and created a novel software program for handheld computers and hypothesized that it would improve clinicians' ability to provide patient-tailored smoking cessation counseling at the point of care. METHODS: A handheld computer software program was created based on smoking cessation guidelines and an adaptation of widely accepted behavioral change theories. The tool was evaluated using a validated before/after survey to measure physician smoking cessation counseling behaviors, knowledge, and comfort/self-efficacy. RESULTS: Participants included 17 physicians (mean age, 41 years; 71% male; 5 resident physicians) from a practice-based research network. After 4 months of use in direct patient care, physicians were more likely to advise patients to stop smoking (P = .049) and reported an increase in use of the "5 As" (P = .03). Improved self-efficacy in counseling patients regarding smoking cessation (P = .006) was seen, as was increased comfort in providing follow-up to patients (P = .04). CONCLUSIONS: Use of a handheld computer software tool improved smoking cessation counseling among physicians and shows promise for translating evidence about smoking cessation counseling into practice and educational settings.

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BACKGROUND: Surveys reveal limited screening and counseling for alcohol misuse by primary care physicians despite evidence-based recommendations. We developed and evaluated an alcohol screening and misuse counseling tool designed to assist clinicians at the point of care (POC). METHODS: This was a mixed methods, prospective cohort study conducted with licensed clinicians in a practice-based research network. A software tool was designed to guide clinicians through evidence-based alcohol misuse assessment and interventions. RESULTS: Participants (N = 12) used the tool an average of 3 sessions and 71% were satisfied with the tool. Participants increased their ability to differentiate between patients who are "at risk" drinkers versus those with alcohol use disorders including dependence/abuse (21%; t = 2.4; P = .04). Thematic analysis of interviews suggests that barriers to overall use included perceptions of alcohol use; clinical need to intervene; time; and issues with use of technology, most often at the POC. However, the tool added confidence and a valuable framework for interventions and was valued as an educational tool. Users felt that increased training and practice could increase comfort and impact future POC use. Increased POC usability also may be achieved through simplification of the tool and additional flexibility in options for POC use. CONCLUSIONS: A computer-assisted counseling tool for alcohol misuse and abuse can be implemented in primary care settings and shows promise for improving physician screening and interventions for alcohol misuse. To enhance utility in daily clinical practice we recommend design enhancements and strategies to enhance usage as described in this research.

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OBJECTIVE: Healthcare providers are under increasing stress and work-related burnout has become common. Mindfulness-based interventions have a potential role in decreasing stress and burnout. The purpose of this study was to determine if a continuing education course based on mindfulness-based stress reduction could decrease burnout and improve mental well-being among healthcare providers, from different professions. DESIGN: This was a pre-post observational study conducted in a university medical center. A total of 93 healthcare providers, including physicians from multiple specialties, nurses, psychologists, and social workers who practiced in both university and community settings, participated. The intervention was a continuing education course based on mindfulness-based stress reduction that met 2.5 hours a week for 8 weeks plus a 7-hour retreat. The classes included training in four types of formal mindfulness practices, including the body scan, mindful movement, walking meditation and sitting meditation, as well as discussion focusing on the application of mindfulness at work. The course was offered 11 times over 6 years. The main outcome measures were work-related burnout as measured by the Maslach Burnout Inventory and self-perceived mental and physical well-being as measured by the SF-12v2. RESULTS: Maslach Burnout Inventory scores improved significantly from before to after the course for both physicians and other healthcare providers for the Emotional Exhaustion (p < 0.03), Depersonalization (p < 0.04), and Personal Accomplishment (p < 0.001) scales. Mental well-being measured by the SF12v2 also improved significantly (p < 0.001). There were no significant changes in the SF12v2 physical health scores. CONCLUSION: A continuing education course based on mindfulness-based stress reduction was associated with significant improvements in burnout scores and mental well-being for a broad range of healthcare providers.

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Despite ongoing efforts to improve working conditions, address well-being of faculty and students, and promote professionalism, many still feel the culture of academic medicine is problematic. Depression and burnout persist among physicians and trainees. The authors propose that culture change is so challenging in part because of an evolutionary construct known as the negativity bias that is reinforced serially in medical education. The negativity bias drives people to attend to and be more greatly affected by the negative aspects of experience. Some common teaching methods such as simulations, pimping, and instruction in clinical reasoning inadvertently reinforce the negativity bias and thereby enhance physicians' focus on the negative. Here, the authors examine the concept of negativity bias in the context of academic medicine, arguing that culture is affected by serially emphasizing the inherent bias to recognize and remember the negative. They explore the potential role of practices rooted in positive psychology as powerful tools to counteract the negativity bias and aid in achieving desired culture change.

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OBJECTIVE: To develop an observational coding instrument for evaluating the fidelity and quality of brief behavioral change interventions based on the behavioral theories of the 5 A's, Stages of Change and Motivational Interviewing. METHODS: Content and face validity were assessed prior to an intervention where psychometric properties were evaluated with a prospective cohort of 116 medical students. Properties assessed included the inter-rater reliability of the instrument, internal consistency of the full scale and sub-scales and descriptive statistics of the instrument. Construct validity was assessed based on student's scores. RESULTS: Inter-rater reliability for the instrument was 0.82 (intraclass correlation). Internal consistency for the full scale was 0.70 (KR20). Internal consistencies for the sub-scales were as follows: MI intervention component (KR20=.7); stage-appropriate MI-based intervention (KR20=.55); MI spirit (KR20=.5); appropriate assessment (KR20=.45) and appropriate assisting (KR20=.56). CONCLUSIONS: The instrument demonstrated good inter-rater reliability and moderate overall internal consistency when used to assess performing brief behavioral change interventions by medical students. PRACTICE IMPLICATIONS: This practical instrument can be used with minimal training and demonstrates promising psychometric properties when evaluated with medical students counseling standardized patients. Further testing is required to evaluate its usefulness in clinical settings.

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BACKGROUND AND OBJECTIVES: There is little research on training medical students in smoking cessation counseling (SCC). This study aimed to determine if a personal digital assistant (PDA)-based SCC tool can improve medical student SCC. METHODS: We conducted a randomized, controlled trial with third-year medical students. SCC behaviors, comfort, and knowledge were assessed using a validated survey before students attended a workshop on SCC. Student groups were then randomized to receive a paper-based reminder tool or the reminder plus a PDA-based SCC tool. The validated survey was repeated upon clerkship completion, and a videotaped standardized patient interview was assessed by trained reviewers using a 24-item SCC checklist. Focus groups assessed satisfaction with the PDA tool, usability, and barriers to use. RESULTS: SCC behaviors, knowledge, and comfort increased among all participants, with no statistical differences between groups. The PDA tool group performed 62% of key SCC activities during the videotaped interview, while the control group performed 69%. Students reported discomfort using the PDA with patients, lack of time, and lack of training as barriers to use of the tool. CONCLUSIONS: We demonstrated improvement of SCC skills by third-year medical students using a workshop combined with a supplemental reference tool. However, a PDA-based tool did not increase key SCC behaviors compared with a paper-based reminder. For a PDA intervention to be effective in this setting, the tool must be simplified and additional training provided.

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Participating in self-assessment activities may stimulate improvement in practice behaviors. However, it is unclear how best to support the development of self-assessment skills, particularly in the health care domain. Exploration of population-based data is one method to enable health care providers to identify deficiencies in overall practice behavior that can motivate quality improvement initiatives. At the University of Virginia, we are developing a decision support tool to integrate and present population-based patient data to health care providers related to both clinical outcomes and non-clinical measures (e.g., demographic information). By enabling users to separate their direct impact on clinical outcomes from other factors out of their control, we may enhance the self-assessment process.

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The goals of this study were to develop a computer-based electronic screening tool (eScreening) and determine the feasibility of implementing eScreening for rural users of primary care. This descriptive pilot adapted existing screening measures for depression and alcohol abuse to a portable computer-based format and examined the feasibility of its adoption and use. This was a three-step design using convenience samples for (1) a focus group with providers, (2) usability testing with selected rural patients using the computerized touch screen, and (3) implementing the touch screen platform with a small sample in primary care to determine feasibility. This paper reports on Phase III, which assessed consumer response to eScreening.

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Despite attention to prevention and screening for depression and alcohol use, Healthy People 2010 objectives continue to include goals to increase the detection of depression and decrease the rates of alcohol abuse. These problems remain significant. The overall goal of this study was to develop a computer-based electronic screening (eScreening) tool and determine the feasibility of implementing computer-based eScreening technology for rural visitors to a primary care clinic. The study called specifically for an electronic touch screen with voice prompts. This tool, called the eScreening tool, screens for alcohol abuse and depression among rural patients in a primary care setting. The screening was offered to rural adults who are not in acute distress and not at end of life, regardless of their stated reason for seeking medical care. Phase 1 of the pilot was used to determine the perceptions of nurses, other providers, and consumers regarding the acceptability and perceived usefulness of an eScreening tool. Phase 2 involved user testing of the eScreening tool. The longer term goals of the research program are to work with rural nurses to improve patient outcomes and develop interventions and for educational, consultation, and/or direct clinical care.

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Improving patient safety and quality in health care is one of medicine's most pressing challenges. Residency training programs have a unique opportunity to meet this challenge by training physicians in the science and methods of patient safety and quality improvement (QI).With support from the Health Resources and Services Administration, the authors developed an innovative, longitudinal, experiential curriculum in patient safety and QI for internal medicine residents at the University of Virginia. This two-year curriculum teaches the critical concepts and skills of patient safety and QI: systems thinking and human factors analysis, root cause analysis (RCA), and process mapping. Residents apply these skills in a series of QI and patient safety projects. The constructivist educational model creates a learning environment that actively engages residents in improving the quality and safety of their medical practice.Between 2003 and 2005, 38 residents completed RCAs of adverse events. The RCAs identified causes and proposed useful interventions that have produced important care improvements. Qualitative analysis demonstrates that the curriculum shifted residents' thinking about patient safety to a systems-based approach. Residents completed 237 outcome assessments during three years. Results indicate that seminars met predefined learning objectives and were interactive and enjoyable. Residents strongly believe they gained important skills in all domains.The challenge to improve quality and safety in health care requires physicians to learn new knowledge and skills. Graduate medical education can equip new physicians with the skills necessary to lead the movement to safer and better quality of care for all patients.This article is part of a theme issue of Academic Medicine on the Title VII health professions training programs.

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BACKGROUND: Successful control of diabetes mellitus requires lifelong adherence to multiple self-management activities in close collaboration with health professionals. We examined the association of such control with appointment keeping behavior in a rural health system. METHODS: Among 4,253 predominantly lower socioeconomic status patients with diabetes, the association of metabolic control (most recent A1c <7% or >9% in two models of respectively 'good' and 'poor' control) with 'missed appointment rate' over a 3-year period was examined using multiple logistic regression. MAIN RESULTS: For each 10% increment in missed appointment rate, the odds of good control decreased 1.12x (p < 0.001) and the odds of poor control increased 1.24x (p < 0.001). The missed appointment rate was substantially higher among African-American patients (15.9% vs. 9.3% for white patients, p < 0.001). Controlling for the missed appointment rate and insurance status in multivariate analysis attenuated the racial association with good control, and the racial association with poor control was no longer significant. Older, white patients with health insurance tended to have significantly better metabolic control. There was no independent association of metabolic control with patient income, gender, or number of primary care visits. CONCLUSION: Adherence to appointments, independent of visit frequency, was a strong predictor of diabetes metabolic control. We hypothesize that missed appointment behavior may serve as an indicator for other diabetes adherence behaviors and associated barriers that serve to undermine successful diabetes self-management.

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Multiple factors are driving residency programs to explicitly address practice-based learning and improvement (PBLI), yet few information systems exist to facilitate such training. We developed, implemented, and evaluated a Web-based tool that provides Internal Medicine residents at the University of Virginia Health System with population-based reports about their ambulatory clinical experiences. Residents use Systems and Practice Analysis for Resident Competencies (SPARC) to identify potential areas for practice improvement. Thirty-three (65%) of 51 residents completed a survey assessing SPARC's usefulness, with 94% agreeing that it was a useful educational tool. Twenty-six residents (51%) completed a before-after study indicating increased agreement (5-point Likert scale, with 5=strongly agree) with statements regarding confidence in ability to access population-based data about chronic disease management (mean [SD] 2.5 [1.2] vs. 4.5 [0.5], p < .001, sign test) and information comparing their practice style to that of their peers (2.2 [1.2] vs. 4.6 [0.5], p < .001).

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