2014, 1–4, Early Online
HOW WE. . .
Continuing professional development in HIV chronic disease management for primary care providers HELEN KANG1, BENITA YIP1, WILLIAM CHAU1, ADRIANA NO´HPAL DE LA ROSA1, DAVID HALL2, ROLANDO BARRIOS1,2,3, JULIO MONTANER1,3 & SILVIA GUILLEMI1 BC Centre for Excellence in HIV/AIDS, Canada, 2Vancouver Coastal Health, Canada, 3HIV/AIDS Research Program, St. Paul’s Hospital, Canada
Med Teach Downloaded from informahealthcare.com by University of California San Francisco on 12/15/14 For personal use only.
1
Abstract Primary care providers need continuing professional development (CPD) in order to improve their knowledge and confidence in the care of patients with chronic conditions. We developed an intensive modular CPD program in the chronic disease management of HIV for primary care providers. The program combines self-directed learning, interactive tutorials with experts, small group discussions, case studies, clinical training, one-on-one mentoring and individualized learning objectives. We trained 27 family physicians and 7 nurse practitioners between 2011 and 2013. The trainees reported high levels of satisfaction with the program. There was a 136.76% increase in the number of distinct HIV-positive patients receiving HIV-related medication refills that were prescribed by the trainees.
Introduction Primary care providers have a critical role in the management of patients with chronic diseases. Primary care providers can make the initial diagnosis and monitor the disease until more specialized care is needed (Katon et al. 2001). However, there are often gaps in knowledge among providers about the latest guidelines or other management issues that can mitigate timely diagnosis and referral, such as for the diagnosis of major depressive disorder (Craven & Bland 2013) or chronic kidney disease (Fox et al. 2006) and more recently on HIV testing (Arya et al. 2014). HIV infection has gone from a fatal illness to a medically managed chronic disease with the introduction of highly active antiretroviral therapy (HAART). Therefore, HIVrelated care must also focus on the complexities of a long-term infection, such as age-related co-morbidities and other chronic complications that include diabetes and cardiovascular disease (Aberg et al. 2014). Primary care physicians with training in HIV can address both primary and HIV-specific care (Kitahata et al. 1996; Landon et al. 2002; Landon et al. 2005) and provide better continuity of care when appropriately partnered with infectious disease specialists (Chu & Selwyn 2011; Burgess & Kasten 2013). These observations align with two components of the chronic care model (CCM): decision support (i.e. integrating evidence-based guidelines into clinical practice) and delivery system design (i.e. coordinated team-based care between primary care providers and specialists) (Barr et al. 2003). In this study, we asked whether an intensive modular training in HIV improves the prescribing of HIV-related medications and provider follow-up for HIV-positive patients.
Practice points
Combine various learning modes into the CPD program. Develop individualized learning plans with the trainees. Select a training site that best allows exposure to teambased care. Partner with a local health authority or other organizations for trainee recruitment and fiscal sustainability of the CPD program. Track the impact of the CPD program by measuring performance improvement of trainees.
What we did Beginning in 2011, the British Columbia Centre for Excellence in HIV/AIDS (BC-CfE) in partnership with the regional health authority, Vancouver Coastal Health (VCH), has offered Intensive Preceptorship Training (IPT) for primary care physicians and nurse practitioners (NPs). The IPT is composed of three modules: online course, clinical rotations and mentorship. VCH recruits and funds the trainees and the BC-CfE provides the training. The goals of this continuing professional development (CPD) program are to build competency in the primary care management and treatment of HIVpositive patients and to establish a connection between primary care providers and the BC-CfE. The BC-CfE develops
Correspondence: Helen Kang, St. Paul’s Hospital, BC Centre for Excellence in HIV/AIDS, 680-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada. Tel: 604-682-2344 ext 63219; Fax: 604-806-9044; E-mail: [email protected] ISSN 0142-159X print/ISSN 1466-187X online/14/000001–4 ß 2014 Informa UK Ltd. DOI: 10.3109/0142159X.2014.970623
1
H. Kang et al.
guidelines, approves and monitors HAART and provides HIV education. Housed at a major downtown hospital, the trainees have access to an in-patient ward and an out-patient clinic that provides inter-professional care for HIV-positive patients.
Med Teach Downloaded from informahealthcare.com by University of California San Francisco on 12/15/14 For personal use only.
Modules in detail In Module 1, trainees complete an online course, which involves approximately 10 h of self-directed study. Afterwards, the trainees establish three to five learning objectives in conversation with the BC-CfE Director of Clinical Education based on their individual strengths and gaps in knowledge. The learning objectives shape the clinical placements and serve as a guide for learning evaluation at the end of Module 2. Module 2 consists of one-week clinical rotations in the HIV out-patient clinic, specialist clinics, hospital wards, HIV clinical pharmacy and women’s HIV clinic. A maximum of three IPT trainees are trained in a given week. Trainees are placed with HIV primary care physicians and ID physicians, as well as specialists of other co-morbidities such as nephrology, endocrinology, addictions medicine, dermatology, etc. On the first day, trainees receive an orientation and three case studies which are later reviewed as a group with the Director. The case review serves as prompts for reflection and as a method of trainee evaluation at the end of the week. During the week, trainees attend daily interactive tutorials that are led by HIV experts. Individual learning objectives are reviewed during the closing session. Table 1 shows a sample schedule for one trainee during Module 2. Module 3 consists of a three-month mentorship during which the trainees are paired with HIV primary care physicians for ongoing support. The mentors and the mentees decide the method and frequency of communication. At the end of their training, family physicians receive CPD credits through the College of Family Physicians of Canada.
Program evaluation Curran and Fleet’s (2005) adaptation of Donald Kirkpatrick’s model identifies four levels of evaluating training programs: (1) learner satisfaction, (2) learning outcomes (i.e. changes in skills, knowledge and attitudes), (3) performance improvement (i.e. impact of acquired skills on behavior) and (4) patient outcomes as a result of the learning activity. We evaluated the IPT from September 2011 to May 2013 at two levels of the adapted Kirkpatrick model: learner satisfaction and performance improvement.
We used a feedback survey to assess learner satisfaction. We asked the trainees to rate (using a five-point ordinal scale ranging from ‘‘Strongly Agree’’ to ‘‘Strongly Disagree’’) the IPT’s effectiveness in meeting their learning objectives and to rate the clinical training’s impact on their competency. We combined the ‘‘Strongly Agree’’ and ‘‘Agree’’ responses to assess trainee satisfaction. We also included several openended questions about the strongest and the weakest aspects of the program and suggestions for improvement. We evaluated the program for performance improvement by comparing HIV-related prescribing patterns by the trainees before and after the IPT. Data for prescribing patterns were obtained from the BC-CfE Drug Treatment Program (DTP) database. The DTP distributes antiretroviral medications free of charge according to the BC-CfE’s therapeutic guidelines. The DTP also collects patient data from HIV-treating physicians in the province, along with the name of the enrolling physician, the requested HIV medications and the date of request. The DTP protocols are approved by the Ethics Review Board of the University of British Columbia-Providence Health Care Research Institute. Approved prescriptions are renewed every 1–3 months and the DTP tracks medication refills. We examined the refill data for the IPT graduates.
Results A total of 34 trainees (27 family physicians and 7 NPs) were trained between September 2011 and May 2013. The trainees’ prescribing pattern was followed from each trainee’s IPT graduation date until February 28, 2014, with a median followup time of 19.5 months (interquartile range: 16.8–22.3 months). There was a 136.76% increase (68 before and 161 after the IPT) in the number of distinct HIV-positive patients receiving HIV-related medication refills that were authorized by the IPT trainees (p ¼ 0.002 Wilcoxon signed-rank test). Completed feedback surveys were received from 24 trainees. High proportions of the respondents reported that the clinical rotations met their learning expectations (n ¼ 20), and helped them to learn to: assess HIV-positive patients and initiate antiretroviral therapy (ART) (n ¼ 23) identify and monitor patients with treatment failures (n ¼ 23) assess HIV-related comorbidities (n ¼ 21) develop a comprehensive care plan (n ¼ 22) engage in an inter-professional framework (n ¼ 23)
Table 1. Sample schedule of Module 2: clinical rotations.
2
Monday
Tuesday
Wednesday
Thursday
08.00–09.00 09.00–12.00 12:00–13:00
Orientation HIV primary care clinic Lunchtime tutorial: ‘‘HIV Treatment Initiation’’
HIV specialty clinic Lunchtime tutorial: ‘‘Primary Care in HIV Patients’’
13:00–15:00 15:00–17:00
HIV metabolic clinic
HIV primary care clinic
HIV ward Lunchtime tutorial: ‘‘Frequent Antiretroviral Therapy Toxicities’’ HIV ward
CPD lecture HIV Pharmacy Lunchtime tutorial: ‘‘Social Issues in HIV Patients’’ Women’s HIV clinic
Friday Hepatitis C clinic Lunchtime tutorial: ‘‘Hepatitis B & C in HIV Patients’’ HIV primary care clinic Closing session
Med Teach Downloaded from informahealthcare.com by University of California San Francisco on 12/15/14 For personal use only.
CPD in HIV chronic disease management
In their written comments to open-ended questions, two trainees stated that the online course was valuable as a foundation. One of these trainees stated that the clinical rotations ‘‘allowed an opportunity to see how to translate the information from the online course and the care guidelines into real life practice’’. Four trainees state that the interactive tutorials were very effective. One of these trainees reported that the tutorials provided ‘‘a chance to ask questions, and to talk to the expert without him/her feeling the pressures of a clinic’’. Five trainees indicated a preference for a longer clinical rotation. One trainee stated that more than a week would be needed to be able to develop comprehensive care plans. Three trainees stated that they would consult with the experts at the BC-CfE, one of whom indicated gaining an understanding of when and who to contact.
sustainability of the program and ongoing education support for trainees. This evaluation demonstrates the need for a study that assesses the long-term impact of the training on patient HIV-related outcomes, such as HIV-RNA plasma viral load, CD4þ cell counts and other chronic disease management indicators like physicians’ visits, hospitalizations, etc. The study will also measure how often the trainees consult with HIV experts and co-morbidity specialists. This study would help to assess the impact of the IPT on the trainee’s ability to engage in the CCM (Barr et al. 2003) in their care of HIVpositive patients, that is, to apply evidence-based guidelines and to work collaboratively with specialists.
Notes on contributors HELEN KANG, PhD, is a clinical educator at the BC Centre for Excellence in HIV/AIDS.
What we did next The IPT trainees’ suggestions for longer clinical rotations to increase confidence in HIV management prompted the BC-CfE to launch Level 2 preceptorship training in September 2013 that consists of three months of clinical rotations. Presently, the BC-CfE is building partnerships with other provincial health authorities to deliver the IPT to primary care providers wanting to deliver HIV care across the province.
Discussion and conclusion Literature on continuing medical education repeatedly demonstrates that interactive learning, such as case discussions and practical training, has greater impact on physician performances and patient outcomes than didactic learning, such as lectures and conferences (Davis et al. 1999; Forsetlund et al. 2009). These findings are supported by the trend in medical education to adopt adult learning principles of learnercentered rather than teacher-centered education (Cantillon & Jones 1999). A combination of two or more different learning modes is shown to have a greater impact on physician behavior (Thomas et al. 2006). The IPT combines several interactive learning techniques: self-directed learning, interactions with experts, small group case discussions, clinical training and one-on-one mentoring. The trainees develop their learning objectives with the guidance of the Director, a process that is learner-centered. Our assessment of the IPT using Curran and Fleet’s (2005) adapted Kirkpatrick model shows that there was high learner satisfaction and a statistically significant performance improvement. There was a 136.76% increase in the number of distinct HIV-positive patients who received HIV-related medication refills prescribed by the trainees after completing IPT. Our findings demonstrate that an intensive modular training in HIV has an impact on the prescribing of HIV-related medications and follow-up for HIV-positive patients. The BC-CfE developed and implemented an innovative modular preceptorship program for the chronic management of HIV-positive patients. In addition to using literaturesupported approaches to CPD, the IPT is a partnership between VCH and BC-CfE, which allows for the fiscal
BENITA YIP, BSc (Pharm), is a data analyst at the BC Centre for Excellence in HIV/AIDS. WILLIAM CHAU, BSc, is a data analyst at the BC Centre for Excellence in HIV/AIDS. ´ HPAL DE LA ROSA, MSc, is a statistician at the BC Centre for ADRIANA NO Excellence in HIV/AIDS. DAVID HALL, MD, is the Medical Director for Primary Care of Vancouver Coastal Health. ROLANDO BARRIOS, MD, FRCPC, is the Assistant Director of the BC Centre for Excellence in HIV/AIDS and Senior Medical Director of Vancouver Coastal Health. JULIO MONTANER, MD, FRCPC, is the Director of the BC Centre for Excellence in HIV/AIDS. SILVIA GUILLEMI, MD, is the Director of Clinical Education at the BC Centre for Excellence in HIV/AIDS.
Acknowledgements We thank Francesca Fung, Education Coordinator at the BCCfE for her administrative work on the program. We also thank the preceptors as well as the family physicians and NPs who participated in the program. Declaration of interest: Dr Montaner is supported by the British Columbia Ministry of Health for the STOP HIV/AIDS Initiative. Other authors report no conflict of interest.
References Aberg JA, Gallant JE, Ghanem KG, Emmanuel P, Zingman BS, Horberg MA. 2014. Primary care guidelines for the management of persons infected with HIV: 2013 update by the HIV Medicine Association of the Infectious Diseases Society of America. Clin Infect Dis 58(1): e1–e34. Arya M, Zheng MY, Amspoker AB, Kallen MA, Street RL, Viswanath K, Giordano TP. 2014. In the routine HIV-testing era, primary care physicians in community health centers remain unaware of HIV-testing recommendations. J Int Assoc Providers AIDS Care 13(4):296–299. Barr VJ, Robinson S, Marin-Link B, Underhill L, Dotts A, Ravensdale D, Salinaras S. 2003. The expanded Chronic Care Model: An integration of concepts and strategies from population health promotion and the Chronic Care Model. Hospital Quarterly 7(1):73–82. Burgess MJ, Kasten MJ. 2013. Human immunodeficiency virus: What primary care clinicians need to know. Mayo Clin Proc 88(12): 1468–1474.
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H. Kang et al.
Cantillon P, Jones R. 1999. Does continuing medical education in general practice make a difference? BMJ 318(7193):1276–1279. Chu C, Selwyn PA. 2011. An epidemic in evolution: The need for new models of HIV care in the chronic disease era. J Urban Health 88(3):556–566. Craven M, Bland R. 2013. Depression in primary care: Current and future challenges. Can J Psychiatry 58(8):442–448. Curran VR, Fleet L. 2005. A review of evaluation outcomes of web-based continuing medical education. Med Educ 39(6):561–567. Davis D, O’Brien M, Freemantle N, Wolf FM, Mazmanian P, Taylor-Vaisey A. 1999. Impact of formal continuing medical education: Do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes? JAMA 282(9):867–874. Forsetlund L, Bjørndal A, Rashidian A, Jamtvedt G, O’Brien MA, Wolf FM, Davis D, Odgaard-Jensen J, Oxman AD. 2009. Continuing education meetings and workshops: Effects on professional practice and health care outcomes. Cochrane Database Syst Rev (2):Art. No. CD003030. DOI: 10.1002/14651858.CD003030.pub2. Fox CH, Brooks A, Zayas LE, McClellan W, Murray B. 2006. Primary care physicians’ knowledge and practice patterns in the treatment of chronic
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kidney disease: An upstate New York practice-based research network (UNYNET) study. J Am Board Family Med 19(1):54–61. Katon W, Von Korff M, Lin E, Simon G. 2001. Rethinking practitioner roles in chronic illness: The specialist, primary care physician, and the practice nurse. Gen Hosp Psychiatry 23(3):138–144. Kitahata MM, Koepsell TD, Deyo RA, Maxwell CL, Dodge WT, Wagner EH. 1996. Physicians’ experience with the acquired immunodeficiency syndrome as a factor in patients’ survival. N Engl J Med 334(11):701–707. Landon BE, Wilson IB, Wenger NS, Cohn SE, Fichtenbaum CJ, Bozzette SA, Shapiro MF, Cleary PD. 2002. Specialty training and specialization among physicians who treat HIV/AIDS in the United States. J Gen Intern Med 17(1):12–22. Landon BE, Wilson IB, McInnes K, Landrum MB, Hirschhorn LR, Marsden PV, Cleary PD. 2005. Physician specialization and the quality of care for human immunodeficiency virus infection. Arch Intern Med 165(10):1133–1139. Thomas DC, Johnston B, Dunn K, Sullivan GM, Brett B, Matzko M, Levine SA. 2006. Continuing medical education, continuing professional development, and knowledge translation: Improving care of older patients by practicing physicians. J Am Geriatr Soc 54(10):1610–1618.
HOW WE. . .
Continuing professional development in HIV chronic disease management for primary care providers HELEN KANG1, BENITA YIP1, WILLIAM CHAU1, ADRIANA NO´HPAL DE LA ROSA1, DAVID HALL2, ROLANDO BARRIOS1,2,3, JULIO MONTANER1,3 & SILVIA GUILLEMI1 BC Centre for Excellence in HIV/AIDS, Canada, 2Vancouver Coastal Health, Canada, 3HIV/AIDS Research Program, St. Paul’s Hospital, Canada
Med Teach Downloaded from informahealthcare.com by University of California San Francisco on 12/15/14 For personal use only.
1
Abstract Primary care providers need continuing professional development (CPD) in order to improve their knowledge and confidence in the care of patients with chronic conditions. We developed an intensive modular CPD program in the chronic disease management of HIV for primary care providers. The program combines self-directed learning, interactive tutorials with experts, small group discussions, case studies, clinical training, one-on-one mentoring and individualized learning objectives. We trained 27 family physicians and 7 nurse practitioners between 2011 and 2013. The trainees reported high levels of satisfaction with the program. There was a 136.76% increase in the number of distinct HIV-positive patients receiving HIV-related medication refills that were prescribed by the trainees.
Introduction Primary care providers have a critical role in the management of patients with chronic diseases. Primary care providers can make the initial diagnosis and monitor the disease until more specialized care is needed (Katon et al. 2001). However, there are often gaps in knowledge among providers about the latest guidelines or other management issues that can mitigate timely diagnosis and referral, such as for the diagnosis of major depressive disorder (Craven & Bland 2013) or chronic kidney disease (Fox et al. 2006) and more recently on HIV testing (Arya et al. 2014). HIV infection has gone from a fatal illness to a medically managed chronic disease with the introduction of highly active antiretroviral therapy (HAART). Therefore, HIVrelated care must also focus on the complexities of a long-term infection, such as age-related co-morbidities and other chronic complications that include diabetes and cardiovascular disease (Aberg et al. 2014). Primary care physicians with training in HIV can address both primary and HIV-specific care (Kitahata et al. 1996; Landon et al. 2002; Landon et al. 2005) and provide better continuity of care when appropriately partnered with infectious disease specialists (Chu & Selwyn 2011; Burgess & Kasten 2013). These observations align with two components of the chronic care model (CCM): decision support (i.e. integrating evidence-based guidelines into clinical practice) and delivery system design (i.e. coordinated team-based care between primary care providers and specialists) (Barr et al. 2003). In this study, we asked whether an intensive modular training in HIV improves the prescribing of HIV-related medications and provider follow-up for HIV-positive patients.
Practice points
Combine various learning modes into the CPD program. Develop individualized learning plans with the trainees. Select a training site that best allows exposure to teambased care. Partner with a local health authority or other organizations for trainee recruitment and fiscal sustainability of the CPD program. Track the impact of the CPD program by measuring performance improvement of trainees.
What we did Beginning in 2011, the British Columbia Centre for Excellence in HIV/AIDS (BC-CfE) in partnership with the regional health authority, Vancouver Coastal Health (VCH), has offered Intensive Preceptorship Training (IPT) for primary care physicians and nurse practitioners (NPs). The IPT is composed of three modules: online course, clinical rotations and mentorship. VCH recruits and funds the trainees and the BC-CfE provides the training. The goals of this continuing professional development (CPD) program are to build competency in the primary care management and treatment of HIVpositive patients and to establish a connection between primary care providers and the BC-CfE. The BC-CfE develops
Correspondence: Helen Kang, St. Paul’s Hospital, BC Centre for Excellence in HIV/AIDS, 680-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada. Tel: 604-682-2344 ext 63219; Fax: 604-806-9044; E-mail: [email protected] ISSN 0142-159X print/ISSN 1466-187X online/14/000001–4 ß 2014 Informa UK Ltd. DOI: 10.3109/0142159X.2014.970623
1
H. Kang et al.
guidelines, approves and monitors HAART and provides HIV education. Housed at a major downtown hospital, the trainees have access to an in-patient ward and an out-patient clinic that provides inter-professional care for HIV-positive patients.
Med Teach Downloaded from informahealthcare.com by University of California San Francisco on 12/15/14 For personal use only.
Modules in detail In Module 1, trainees complete an online course, which involves approximately 10 h of self-directed study. Afterwards, the trainees establish three to five learning objectives in conversation with the BC-CfE Director of Clinical Education based on their individual strengths and gaps in knowledge. The learning objectives shape the clinical placements and serve as a guide for learning evaluation at the end of Module 2. Module 2 consists of one-week clinical rotations in the HIV out-patient clinic, specialist clinics, hospital wards, HIV clinical pharmacy and women’s HIV clinic. A maximum of three IPT trainees are trained in a given week. Trainees are placed with HIV primary care physicians and ID physicians, as well as specialists of other co-morbidities such as nephrology, endocrinology, addictions medicine, dermatology, etc. On the first day, trainees receive an orientation and three case studies which are later reviewed as a group with the Director. The case review serves as prompts for reflection and as a method of trainee evaluation at the end of the week. During the week, trainees attend daily interactive tutorials that are led by HIV experts. Individual learning objectives are reviewed during the closing session. Table 1 shows a sample schedule for one trainee during Module 2. Module 3 consists of a three-month mentorship during which the trainees are paired with HIV primary care physicians for ongoing support. The mentors and the mentees decide the method and frequency of communication. At the end of their training, family physicians receive CPD credits through the College of Family Physicians of Canada.
Program evaluation Curran and Fleet’s (2005) adaptation of Donald Kirkpatrick’s model identifies four levels of evaluating training programs: (1) learner satisfaction, (2) learning outcomes (i.e. changes in skills, knowledge and attitudes), (3) performance improvement (i.e. impact of acquired skills on behavior) and (4) patient outcomes as a result of the learning activity. We evaluated the IPT from September 2011 to May 2013 at two levels of the adapted Kirkpatrick model: learner satisfaction and performance improvement.
We used a feedback survey to assess learner satisfaction. We asked the trainees to rate (using a five-point ordinal scale ranging from ‘‘Strongly Agree’’ to ‘‘Strongly Disagree’’) the IPT’s effectiveness in meeting their learning objectives and to rate the clinical training’s impact on their competency. We combined the ‘‘Strongly Agree’’ and ‘‘Agree’’ responses to assess trainee satisfaction. We also included several openended questions about the strongest and the weakest aspects of the program and suggestions for improvement. We evaluated the program for performance improvement by comparing HIV-related prescribing patterns by the trainees before and after the IPT. Data for prescribing patterns were obtained from the BC-CfE Drug Treatment Program (DTP) database. The DTP distributes antiretroviral medications free of charge according to the BC-CfE’s therapeutic guidelines. The DTP also collects patient data from HIV-treating physicians in the province, along with the name of the enrolling physician, the requested HIV medications and the date of request. The DTP protocols are approved by the Ethics Review Board of the University of British Columbia-Providence Health Care Research Institute. Approved prescriptions are renewed every 1–3 months and the DTP tracks medication refills. We examined the refill data for the IPT graduates.
Results A total of 34 trainees (27 family physicians and 7 NPs) were trained between September 2011 and May 2013. The trainees’ prescribing pattern was followed from each trainee’s IPT graduation date until February 28, 2014, with a median followup time of 19.5 months (interquartile range: 16.8–22.3 months). There was a 136.76% increase (68 before and 161 after the IPT) in the number of distinct HIV-positive patients receiving HIV-related medication refills that were authorized by the IPT trainees (p ¼ 0.002 Wilcoxon signed-rank test). Completed feedback surveys were received from 24 trainees. High proportions of the respondents reported that the clinical rotations met their learning expectations (n ¼ 20), and helped them to learn to: assess HIV-positive patients and initiate antiretroviral therapy (ART) (n ¼ 23) identify and monitor patients with treatment failures (n ¼ 23) assess HIV-related comorbidities (n ¼ 21) develop a comprehensive care plan (n ¼ 22) engage in an inter-professional framework (n ¼ 23)
Table 1. Sample schedule of Module 2: clinical rotations.
2
Monday
Tuesday
Wednesday
Thursday
08.00–09.00 09.00–12.00 12:00–13:00
Orientation HIV primary care clinic Lunchtime tutorial: ‘‘HIV Treatment Initiation’’
HIV specialty clinic Lunchtime tutorial: ‘‘Primary Care in HIV Patients’’
13:00–15:00 15:00–17:00
HIV metabolic clinic
HIV primary care clinic
HIV ward Lunchtime tutorial: ‘‘Frequent Antiretroviral Therapy Toxicities’’ HIV ward
CPD lecture HIV Pharmacy Lunchtime tutorial: ‘‘Social Issues in HIV Patients’’ Women’s HIV clinic
Friday Hepatitis C clinic Lunchtime tutorial: ‘‘Hepatitis B & C in HIV Patients’’ HIV primary care clinic Closing session
Med Teach Downloaded from informahealthcare.com by University of California San Francisco on 12/15/14 For personal use only.
CPD in HIV chronic disease management
In their written comments to open-ended questions, two trainees stated that the online course was valuable as a foundation. One of these trainees stated that the clinical rotations ‘‘allowed an opportunity to see how to translate the information from the online course and the care guidelines into real life practice’’. Four trainees state that the interactive tutorials were very effective. One of these trainees reported that the tutorials provided ‘‘a chance to ask questions, and to talk to the expert without him/her feeling the pressures of a clinic’’. Five trainees indicated a preference for a longer clinical rotation. One trainee stated that more than a week would be needed to be able to develop comprehensive care plans. Three trainees stated that they would consult with the experts at the BC-CfE, one of whom indicated gaining an understanding of when and who to contact.
sustainability of the program and ongoing education support for trainees. This evaluation demonstrates the need for a study that assesses the long-term impact of the training on patient HIV-related outcomes, such as HIV-RNA plasma viral load, CD4þ cell counts and other chronic disease management indicators like physicians’ visits, hospitalizations, etc. The study will also measure how often the trainees consult with HIV experts and co-morbidity specialists. This study would help to assess the impact of the IPT on the trainee’s ability to engage in the CCM (Barr et al. 2003) in their care of HIVpositive patients, that is, to apply evidence-based guidelines and to work collaboratively with specialists.
Notes on contributors HELEN KANG, PhD, is a clinical educator at the BC Centre for Excellence in HIV/AIDS.
What we did next The IPT trainees’ suggestions for longer clinical rotations to increase confidence in HIV management prompted the BC-CfE to launch Level 2 preceptorship training in September 2013 that consists of three months of clinical rotations. Presently, the BC-CfE is building partnerships with other provincial health authorities to deliver the IPT to primary care providers wanting to deliver HIV care across the province.
Discussion and conclusion Literature on continuing medical education repeatedly demonstrates that interactive learning, such as case discussions and practical training, has greater impact on physician performances and patient outcomes than didactic learning, such as lectures and conferences (Davis et al. 1999; Forsetlund et al. 2009). These findings are supported by the trend in medical education to adopt adult learning principles of learnercentered rather than teacher-centered education (Cantillon & Jones 1999). A combination of two or more different learning modes is shown to have a greater impact on physician behavior (Thomas et al. 2006). The IPT combines several interactive learning techniques: self-directed learning, interactions with experts, small group case discussions, clinical training and one-on-one mentoring. The trainees develop their learning objectives with the guidance of the Director, a process that is learner-centered. Our assessment of the IPT using Curran and Fleet’s (2005) adapted Kirkpatrick model shows that there was high learner satisfaction and a statistically significant performance improvement. There was a 136.76% increase in the number of distinct HIV-positive patients who received HIV-related medication refills prescribed by the trainees after completing IPT. Our findings demonstrate that an intensive modular training in HIV has an impact on the prescribing of HIV-related medications and follow-up for HIV-positive patients. The BC-CfE developed and implemented an innovative modular preceptorship program for the chronic management of HIV-positive patients. In addition to using literaturesupported approaches to CPD, the IPT is a partnership between VCH and BC-CfE, which allows for the fiscal
BENITA YIP, BSc (Pharm), is a data analyst at the BC Centre for Excellence in HIV/AIDS. WILLIAM CHAU, BSc, is a data analyst at the BC Centre for Excellence in HIV/AIDS. ´ HPAL DE LA ROSA, MSc, is a statistician at the BC Centre for ADRIANA NO Excellence in HIV/AIDS. DAVID HALL, MD, is the Medical Director for Primary Care of Vancouver Coastal Health. ROLANDO BARRIOS, MD, FRCPC, is the Assistant Director of the BC Centre for Excellence in HIV/AIDS and Senior Medical Director of Vancouver Coastal Health. JULIO MONTANER, MD, FRCPC, is the Director of the BC Centre for Excellence in HIV/AIDS. SILVIA GUILLEMI, MD, is the Director of Clinical Education at the BC Centre for Excellence in HIV/AIDS.
Acknowledgements We thank Francesca Fung, Education Coordinator at the BCCfE for her administrative work on the program. We also thank the preceptors as well as the family physicians and NPs who participated in the program. Declaration of interest: Dr Montaner is supported by the British Columbia Ministry of Health for the STOP HIV/AIDS Initiative. Other authors report no conflict of interest.
References Aberg JA, Gallant JE, Ghanem KG, Emmanuel P, Zingman BS, Horberg MA. 2014. Primary care guidelines for the management of persons infected with HIV: 2013 update by the HIV Medicine Association of the Infectious Diseases Society of America. Clin Infect Dis 58(1): e1–e34. Arya M, Zheng MY, Amspoker AB, Kallen MA, Street RL, Viswanath K, Giordano TP. 2014. In the routine HIV-testing era, primary care physicians in community health centers remain unaware of HIV-testing recommendations. J Int Assoc Providers AIDS Care 13(4):296–299. Barr VJ, Robinson S, Marin-Link B, Underhill L, Dotts A, Ravensdale D, Salinaras S. 2003. The expanded Chronic Care Model: An integration of concepts and strategies from population health promotion and the Chronic Care Model. Hospital Quarterly 7(1):73–82. Burgess MJ, Kasten MJ. 2013. Human immunodeficiency virus: What primary care clinicians need to know. Mayo Clin Proc 88(12): 1468–1474.
3
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