Original Research

Group 1: Presented by Monica Ethirajan, MS, MPH

Authors:  Ethirajan, Alexon Munson-Catt, MS; Jordan Goodmurphy; Felicia Toreno, PhD, RDMS, RDCS, RVT; Craig W. Goodmurphy, PhD

As a noninvasive tool, many practitioners have incorporated ultrasound into regular clinical practice and is becoming an integral part of the basic standard of care for patients. Many medical schools have integrated some form of ultrasound training into their undergraduate medical curricula. Introducing simulations to ultrasound during medical training has helped closed the gap between didactic classroom training and clinical patient care. These clinical procedures must not only be introduced, but also practiced, at the undergraduate level to ensure that students have the confidence and knowledge to perform these same ultrasound-guided procedures on a live patient.

Patient preference surveys have revealed that patients are unwilling to allow a medical student to perform any sort of procedure on them at all if it is their first time doing so. Appropriate training, guided practice, and repetitive exposure to performing these clinical procedures should be a mainstay in ultrasound training during the didactic years of medical school. The importance of teaching clinical ultrasound procedures lies less in achieving proficiency and more in developing a psychomotor skill set that is translatable across several procedures.

The introduction and development of the underlying psychomotor manipulation required to develop a broad range of skill sets are crucial during undergraduate medical education to refine these techniques later in a clinical setting. While learners new to the technique are apt to make mistakes, introducing these skills early in medical training allows students to hone and develop a marketable skill set, which can then be further developed during residency training. Introducing these clinical-type procedures in a safe teaching environment can help to improve future patient safety and potentially maximize future outcomes.

EVMS introduced this skill using trainers constructed with cadaver tissue (thyroid gland and trachea) and ZerdineTM, a polyacrylamide hydrogel. The thyroid tissue included cysts created from ZerdineTM and embedded behind the thyroid gland.

One hundred and forty-six second-year medical students located the cystic structures and captured the image under ultrasound guidance. Students obtained another image with a needle inserted into the same cystic structure to practice their skills in ultrasound-guided fine needle aspirations (USGFNAs). Following this exercise, students completed a four-question survey and their images were evaluated by both peers and instructors.

Every student was successfully able to acquire the necessary images. Most students found the trainers both effective (4.67 out of 5) and anatomically accurate (4.53 out of 5). They indicated an interest in performing additional similar ultrasound-guided procedures in their curriculum (4.68 out of 5). Most of the open-ended questions resulted in positive feedback (66%). Grader critique decreased from the first to the second day (56% vs 40%) and most of the critique recommended improvements with depth of the image (66%). Students found the trainers to be realistic, effective and enjoyable. Continuing to provide more training and expanding on students’ development of their psychomotor skill set can prove to be invaluable in delivering effective value-based care to future patients.

Group 2: Presenter Sarah Alnaif, BHSc

Authors: Alnaif; Tram Phung; Ying Li, MD; Qi Lin, MD; Hongyun Fu, PhD

Introduction: In response to the devastating opioid crisis in the United States, the Centers for Disease Control (CDC) released the Guideline for Prescribing Opioids for Chronic Pain in 2016, with subsequent legislation enacted to regulate the use of opioid prescription at the state level. Concerns were raised that the pressure of the 2016 guideline may have led to an unintended reduction in opioid prescription use in palliative care and compromised patients’ wellbeing. However, limited empirical research has been conducted to inform our understanding on this issue. 

Methods: From June to August 2020, we conducted in-depth interviews with a convenience sample of health care providers (N=14) to understand their experiences with and attitudes toward the 2016 CDC Guideline and its influence on opioid prescribing practices. Respondents were recruited in palliative/hospice care and primary care settings through a snowball sampling method and peer-referral networks in Hampton Roads. In-depth interviews (approximately 45 minutes each) were conducted using BlueJeans (a cloud-based video conferencing platform) following a semi-structured interview guideline. Interviews were transcribed and data was coded into themes, guided by the Social Ecological Model of Health Behaviors and Outcomes.

Results: Overall, healthcare providers voiced that the 2016 Guideline has been over-interpreted, causing barriers to, and stigma associated with, the use of opioid prescription for palliative care at three levels:

1. Policy level: We found reduced drug production and supply, more stringent monitoring of opioid prescribing, and more restrictive insurance reimbursement policy;
2. Health care provider level: There were concerns of being the “top prescriber on the list”, extra precautions and unwillingness to prescribe opioid medication, as well as concerns over increasing gaps in service referrals and care transitions between in-patient and out-patient care as well as across specialty areas;
3. Patient level: There were misunderstandings about certain opioid medications, concerns over drug dependence and addiction, cautions/hesitancy about initiating opioid prescription, and gaps in access to opioid prescription for needy patients, particularly during care transition. Primary care physicians talked about the extra precautions that had to be taken as well as limitations on the number and types of medications, while palliative care providers raised more concerns over stigma associated with opioid drugs and increasing unmet needs for treatment during care transition.

Conclusions: Our findings indicated that the 2016 CDC Guideline has increased precautions regarding opioid prescription use among both healthcare providers and patients, leading to a reduced demand for and use of opioid prescriptions. As a result, the Guideline has been over-interpreted, leading to the pendulum swinging from over-prescribing to under-prescribing opioid medication. This has resulted in unmet needs within patient populations who were not supposed to be included in the Guideline (e.g., those receiving palliative care). Furthermore, the widened gaps in care transitions after discharge from inpatient care settings also points to the need for outpatient palliative care services in Hampton Roads. There is evidence of unmet need for targeted health communication and education trainings for both patients and physicians to reduce misconceptions about opioid medications.