The Permanente journal最新文献

Background: Trauma is common in the United States, increases risk of long-term adverse health effects, and individuals who experience it often find seeking medical care difficult. Trauma-informed care (TIC) builds trust and fosters healing relationships between clinicians and patients; however medical education has lacked consistent training in TIC. Using recently published competencies for undergraduate medical education (UME), this manuscript provides curricular examples across 8 domains to assist faculty in developing educational content.

Methods: The authors identified published curricula for each of the 8 competency domains using a published search strategy and publicly available database. Inclusion criteria were published works focused on UME in the United States; abstracts and curricula not focused on UME were excluded. The authors used a consensus-based process to review 15 eligible curricula for mapping with the competencies.

Results: Of 15 published UME curricula, 11 met criteria and exemplify each of the 8 UME competency domains. Most of the available curricula fall into the Knowledge for Practice and Patient Care domains. Most were offered in the first 2 years of medical school.

Conclusion: Competency-based medical education for TIC is new, and most current educational offerings are foundational in nature. Additional innovation is needed in the competency domains of Professionalism, Systems-Based Practice, Interprofessional Collaboration, and Personal/Professional Development. This manuscript offers a set of curricular examples that can be used to aid efforts at implementing TIC competencies in UME; future work must focus on improving assessment methods and developmental sequencing as more students are exposed to TIC principles.

Clinical empathy is a multidimensional ability to feel the patient's suffering, branched into components such as cognitive, emotional, and action, which results in benefits for patients, parents, health professionals, medical students, and others. The authors performed a critical review of the literature about empathy in neonatal care, in 2 databases, and analyzed the co-occurrence of keywords in the last 10 years. Nine articles were included in the qualitative synthesis. They highlight the interconnection between empathy, communication, ethics, and palliative care. Empathy was analyzed in situations that included pain, death, and suffering in the neonate, especially related to critically ill neonates. Strategies such as self-reflection and digital storytelling may help increase the clinical empathy education of health professionals. There are gaps in research considering the measurement of clinical empathy in neonatal care, and this measurement should be encouraged. To change care practices, education on empathy for health professionals, especially physicians, should be improved.

Introduction: Advanced Care at Home is a clinical model that delivers hospital-level care in a patient's home. This model of care has been studied for decades, but there have been difficulties scaling the model to a higher census because of poor physician participation. Kaiser Permanente at Home, an Advanced Care at Home model created by Kaiser Permanente Northwest, was able to quickly increase its patient census by using several different change management interventions. The aim of this study was to describe the specific physician change management interventions used and to determine their relative impacts on physician participation with Kaiser Permanente at Home.

Methods: This study used a retrospective qualitative approach. Hospitalist and emergency department (ED) physicians completed an online survey in December 2021. This was followed by focused, one-on-one interviews that were held in February 2022. Content analysis was performed using a general inductive approach to identify core themes.

Results: Of 78 ED and 79 hospitalist physicians recruited, 35% submitted responses. Of these respondents, 16 (29%) were ED physicians, and 39 (61%) were hospitalist physicians. Of these respondents, 90% rated Kaiser Permanente at Home favorably over the course of a year. More than 90% of respondents rated a combination of multiple approaches as impactful, but respondents overwhelmingly noted that physician-to-physician engagement was the most important (51%).

Conclusion: In the development of the Kaiser Permanente at Home, physicians highlighted that a multifactorial change management approach centered on peer-to-peer engagement had the most substantial effect on their participation, a process that could extend up to a year.

Introduction: Ambulatory clerkships, including longitudinal integrated clerkships (LICs), face challenges to assessment, including time pressure and clinical demands on preceptors. High-quality clinical assessment is critical to implementing competency-based medical education, generating valid grades, and supporting learning. This importance is further heightened with the new pass/fail scoring for US Medical Licensing Exam Step 1, discontinuation of US Medical Licensing Exam Step 2 Clinical Skills, and the growing concern for bias in assessment.

Methods: The Kaiser Permanente Bernard J. Tyson School of Medicine's LIC spans the first 2 years with 50 students per class. In 2021-2022, the authors created a new faculty role, the clinical assessment specialist (CASp). CASps are highly trained clinical teachers who directly observe clerkship students in the ambulatory setting, provide feedback, and complete competency-based assessment forms.

Results: CASps completed 186 assessments of first-year (Y1) LIC students and 333 assessments of second-year (Y2) LIC students. Y2 students achieved average higher milestones and were rated as requiring less supervision compared to Y1 students. Y1 students rated CASps more favorably than Y2 students. Preceptors rated the contribution of CASps similarly across both years. Clerkship directors described benefits including identification of at-risk students and value of augmenting preceptor assessments.

Discussion: The CASp role may offer an innovative way to generate valid assessment of student performance, offset clinical pressures faced by preceptors, identify at-risk students, and mitigate bias, especially in an LIC. Future studies may examine assessment validity, including use in summative assessment.

Conclusion: CASps are an innovative approach to clinical clerkship assessment.

Background: Maternal history of trauma is a risk factor for distress during pregnancy. The purpose of this paper was to examine the theorized differential impact of a cognitive behavioral intervention (Mothers and Babies Personalized; MB-P) on maternal distress and emotional regulation for those with ≥ 1 adverse childhood experiences (ACEs; vs no ACEs) from pregnancy to 3 months postpartum.

Methods: Between August 2019 and August 2021, eligible pregnant individuals aged ≥ 18 years, < 22 weeks' gestation, and English-speaking were recruited from 6 university-affiliated prenatal clinics. Participants (N = 100) were randomized to MB-P (n = 49) or control (n = 51). Analyzable data were collected for 95 participants. Analyses tested progression of change (slope) and at individual timepoints (panel analysis) for perinatal mental health outcomes.

Results: The majority of participants (n = 68, 71%) reported experiencing > 1 ACE (median = 1, range: 0-11). Participants demonstrated significant differential effects for depressive symptoms in absence of ACEs (standardized mean differences [SMD] = 0.82; 95% confidence interval [CI] = [0.13-1.51]) vs in presence of ACEs (SMD = 0.39; 95% CI = [-0.20 to 0.97]) and perceived stress in absence of ACEs (SMD = 0.92; 95% CI = [0.23-1.62]) vs in presence of ACEs (SMD = -0.05; 95% CI = [-0.63 to 0.53]). A panel analysis showed significantly reduced depressive symptoms postintervention and increased negative mood regulation at 3 months postpartum for individuals with ACEs.

Conclusions: Findings support effectiveness of the MB-P intervention to reduce prenatal distress for all pregnant individuals. Preliminary exploration suggests the possibility that individuals with ACEs may benefit from enhanced trauma-informed content to optimize the effects of a perinatal intervention.

Introduction: Patients are being encouraged to complete forms electronically using patient portals rather than on paper, but willingness of older adults to make this transition is uncertain.

Methods: The authors analyzed data for 4105 Kaiser Permanente Northern California 2020 Member Health Survey respondents aged 65-85 years who answered a question about willingness to complete online forms and questionnaires using a patient portal. Data weighted to the Kaiser Permanente Northern California membership were used to estimate percentages of older adults willing to complete patient portal forms and questionnaires. Chi-square tests and log-Poisson regression models that included sociodemographic, internet use, and patient portal variables were used to identify factors predictive of willingness.

Results: Overall, 59.6% of older adults were willing to complete patient portal forms, 17.6% were not willing, and 22.8% were not sure. Adults aged 75-85 (49.5%) vs 65-74 years (64.8%) and Black (51.9%) and Latino (46.5%) vs White (62.8%) adults were less likely to indicate willingness. In addition to racial and ethnic differences and younger age, higher educational attainment, use of the internet alone (vs internet use with help or not at all), having an internet-enabled computer or tablet, and having sent at least 1 message through the patient portal increased likelihood of being willing.

Conclusions: Health care teams should assess older adults' capabilities and comfort related to completion of patient portal-based forms and support those willing to make the digital transition. Paper forms and oral collection of information should remain available for those unable or unwilling to make this digital transition.

Background: Screening for adverse childhood experiences (ACEs) in prenatal and pediatric populations is recommended by the California ACEs Aware initiative and is a promising practice to interrupt ACEs in children and mitigate ACEs-related health complications in children and families. Yet, integrating ACEs screening into clinical practice poses several challenges.

Objective: The objective of this report was to evaluate the Kaiser Permanente Northern California and Kaiser Permanente Southern California pilots and implementation of ACEs screening into routine prenatal (Kaiser Permanente Northern California) and pediatric (Kaiser Permanente Southern California) care.

Materials and methods: These pilots were evaluated and compared to identify common challenges to implementation and offer promising practices for negotiating these challenges. Evaluation methods included feedback from staff, clinicians, and patients, as well as comparisons of methods to overcome various barriers to screening implementation.

Results: Implementing ACEs screening, like implementation of any new component of clinical care, takes careful planning, education, creation of content and workflows, and continuous integration of feedback from both patients and staff.

Conclusion: This evaluation can serve as support for care teams who are considering implementing ACEs screening or who are already screening for ACEs. More research is needed regarding the relationship between ACEs and preventable and treatable health outcomes to improve health for patients and their families.

Introduction: For academic promotion, clinical faculty are expected to excel in clinical care, teaching, and scholarship. Ensuring adequate protected time and resources to engage in scholarly work in the face of competing clinical responsibilities is critical. The authors examined academic leaders' perspectives across affiliate hospitals of a large medical school regarding the definition of clinical full-time effort and academic time, best practices to enable academic success, and barriers to faculty advancement.

Methods: Open-ended, semistructured, individual interviews were conducted with a purposive sample of clinical department and division heads. Interview data were examined to illuminate the range and commonalities in practices and to identify successful approaches.

Results: Interviews were conducted with 17 academic leaders across 6 affiliate hospitals. There was considerable variability in clinical full-time effort definition. "Academic time," more accurately characterized as "nonclinical time," was typically 1 day a week for nonshift specialties and mostly used for administrative work or completing clinical documentation. Certain departments were more explicit in designating and protecting time for academic pursuits; some had invested resources in intensive programs for academic advancement with built-in expectations for accountability. The impact of documentation burden was considerable in certain departments.

Discussion and conclusion: Marked variability exists in time allocations for clinical and academic work, as well as in resources for academic success. This supports the potential value of establishing standards for defining and protecting academic time, motivating clinical faculty to engage in academic work, and building accountability expectations. Sharing best practices and setting standards may enhance academic advancement. Strategies to reduce documentation burden may enhance wellness.