Text 4 Success in Gestational Diabetes Interim Report: Internal testing and iterative improvements

Rachel Blair, MD

Fellow in the Division of Endocrinology, Diabetes and Hypertension at Brigham and Women’s Hospital

PGY6

03/13/2020

I am developing a text messaging program for women with gestational diabetes, which is diabetes diagnosed during the 3^rd trimester of pregnancy. The program is designed to provide reminders to check blood sugars, as well as educational and motivational messages. The program also sends encouraging replies when women send in their blood sugars.

Screenshot showing some of
the messages. 

I previously designed a novel text message library and obtained feedback from women with gestational diabetes on the wording and content of messages. The current stage of my project, supported by funding from the COE for Health Policy and Management, is performing usability testing. We are working with a vendor to create a text messaging platform with our content. We then plan to enroll women for a two week period followed by interviews to obtain feedback and to determine if it is easy to use and acceptable.

We have been working extensively with our vendor to rigorously test the product before enrolling participants. We have discovered additional scenarios during testing for which we needed to create new messages (such as – what if someone sends in a blood sugar number unprompted?).  There have been technical limitations and we’ve come up with some creative solutions (for example, emojis cannot be included in the program, so we are using :-) in one of our messages instead).

Next steps will include having women with gestational diabetes use the program once all technical issues have been resolved. That being said, recruitment will likely need to be postponed because of COVID-19. The findings of our work creating the message library were accepted for a poster presentation at the Endocrine Society Meeting in 2020.

I have learned that there are many unexpected roadblocks and limitations when designing a new intervention, and it is important to be creative when coming up with solutions for those roadblocks.

Improving quality of care for people who inject drugs seeking care at Massachusetts General Hospital

Dinah P. Applewhite, M.D. 

Fellow in Addiction Medicine at Massachusetts General Hospital

PGY-4

03/06/2020

Injection of drugs such as opioids, methamphetamine and cocaine, carries with it many risks, including venous damage, overdose, and infections. When people who inject drugs (PWID) interface with the medical system, there are often are missed opportunities for healthcare workers to facilitate safer injection among PWID. This study aims to better understand injection practices and factors contributing to those practices, such as knowledge, attitudes, access to injection supplies, and structural determinants of health.

Example of safer injection supplies

The survey has been approved by the IRB and we are now piloting it among group of PWID. The timeline is behind schedule by two months due to delays getting the final approval by the IRB. The delay was in large part because of a technical error I made when responding to the initial review. I made the mistake of deleting the original documents, which resulted in a very prolonged and frustrating process consisting of multiple phone calls with IRB staff and resubmissions. Last week when I got the final IRB approval, I felt such a wave of relief. Lesson learned (which seems so obvious in retrospect): Read the IRB instructions--your mistakes will cost you time!  

I am excited to administer the survey over the next few months. We have a fantastic team of research staff and volunteers. Ultimately, we will use this data to inform an intervention to improve the quality of care for PWID who seek care at MGH. This intervention will involve facilitating access to safer injection supplies and harm reduction messaging around safer injection techniques.

A PAUSE in Process: Successes and hurdles as we prepare to PAUSE more in the BWH Internal Medicine Residency Program.

Allison Vise MD

Resident in the Internal Medicine Residency Program at BWH/HVMA

PGY2

03/01/2020

Residents on the inpatient medical service must provide high quality care for acutely ill patients, lead interdisciplinary rounds, communicate with patients and families, and supervise a team of junior residents and students. Residents are expected to be proficient at participation in such high stakes clinical events and sometimes even lead them, without any dedicated training or overt support. Currently, post-event debriefings are happenstance, unstructured, and any debriefing typically focuses on aspects of the clinical setting and management rather than the emotions of clinicians. The emotional burden that accompanies acute patient care, especially among young trainees, is a recipe for consequences associated with burnout.

I am interested in teaching my peers how to facilitate debriefings well, and I am eager to study the effects of such a program. My Partners Center of Expertise-funded medical education research project is called PAUSE, which stands for Prepare, Analyze, Understand, Sentiment, Educate, the five steps of the PAUSE debriefing. PAUSE is an educational program that includes: 1) Creating a brief and interactive educational session about debriefing challenging situations (mistakes, codes, patient deaths, a week of inpatient work, or any other stressful situation), 2) Producing a physical tool that providers can use to facilitate such conversations, 3) Implementing the tool in our residency program and hospital, and 4) Studying the usefulness of the tool through both qualitative and quantitative methods.

Allison facilitating a PAUSE in the new PAUSE training video 

Over the past six months since I was awarded the COE grant, I have made progress on developing PAUSE, with the support of my Scholars in Medical Education Pathway co-residents and my mentors in the Departments of Medicine and Palliative Care. Specifically, I announced PAUSE to my residency program in December, to great excitement and support from my co-residents. A co-resident and I wrote and directed a training film, featuring other co-residents as actors who had just been at an imagined Code Blue. This film models a PAUSE, and is part of our training program (see image). And, with COE funding, I have created the physical tool, an easy to carry badge that will conveniently attach to providers’ ID lanyards in the hospital. I have solicited and been given permission by the medical director of the Shapiro Levine Cardiac Intensive Care Unit to roll-out our program there, given the high rate of intense events that occur, and the incredibly intimate work environment between nurses, pharmacists, PCAs, and physicians there. All in the program are excited to start using PAUSE in our hospital.

My biggest obstacle to implementation so far has been IRB approval. I have been waiting to roll-out the tool on the hospital floors until I have IRB final approval, so that I can proceed with surveys and focus groups as planned. I have learned much about the IRB process while working on PAUSE. Specifically, I have learned about the components of an education project IRB proposal that matter most. After several rounds of edits, I recently re-submitted my IRB, and eagerly await its approval.

Going forward, I am looking forward to teaching PAUSE to select groups of Internal Medicine program residents for this pilot phase. And, I am writing a curriculum to teach it to all outgoing Internal Medicine interns at the end of this year during their retreat that prepares them for their PGY-2 year. This will mean that all PGY-2 Internal Medicine residents will be ready to lead PAUSE debriefings when they become team leaders in a few short months.

I am most grateful for the support I have received from the Partners Center of Expertise in Medical Education, and I am excited to implement PAUSE soon.

Effective Senior Residents, as Defined by Their Peers: A Qualitative Assessment

Taylor Coe, MD

PGY4

General Surgery Resident

Department of Surgery

Massachusetts General Hospital
02/29/2020

Surgical training aims to create doctors who are clinically competent and technically sound; however, there are many nontechnical skills that are imperative to surgical practice as well.  These include, and are not limited to, team leadership and management, teaching of all members of the team, such as patients, medical students, advanced care providers and junior residents, communication, and providing feedback. There is a clear change in role and responsibility that occurs as one transitions from being a junior to a senior resident in which these nontechnical skills become more prominent and central to successful patient care and team leadership.  Therefore, I plan to use qualitative methods to define what makes an effective senior surgical resident and the current process of leadership and nontechnical skills development in the transition from junior to senior surgical resident.

As all projects begin, first I navigated IRB approval. This was a monumental exercise for me, as it was my first IRB application and my first project of my own generation from start to finish. I drafted my proposal and focus group guide and finally submitted, about two months later than I had initially hoped. My first takeaway from this project is that sometimes, the hardest part is just getting started. This task was intimidating and I delayed submission due to my own fears of sharing my work and navigating a new process. Ultimately, I received approval after a round of revisions and was ready to start my focus groups.

Fellows of the MGH Surgical Education Research Group

Here, my first lesson comes into play again. I had approval to start, but now I had to actually recruit the first residents for a focus group. This task brought up a mix of emotions again. I was intimidated to ask my peers to volunteer one hour of their time and to put my research out in the open and receive feedback about a project that I developed and nurtured. The theme continues, in which it took me two extra months to work up the courage to embark on my first focus groups; however, once I started, I found them to be an incredibly insightful and rewarding experience that was beneficial for my work, but also for the participating residents.

So far, I have completed ten focus groups with 23 residents spanning PGY2 to PGY4 residents. I am scheduling the PGY1 and PGY5 residents and will be finished collecting data by the end of March. From there, my next task is qualitative analysis of over fifteen hours of transcription. On preliminary review of the first few focus groups, there are interesting findings starting to take shape. In an effort to first define a senior resident, it is clear that the senior resident has ‘extreme ownership’ of the team resulting in ‘complete responsibility for the patient experience’. The senior resident is viewed as a role model, teacher, and leader who is responsible for not only clinical and technical excellence, but also for management of team morale and creating opportunities for junior autonomy and junior wellness. These skills are mostly obtained through ‘osmosis’ through the gradual transition from junior to senior, with minimal structured education.

Overall, this project has been a wonderful experience for both my own personal growth as a researcher and in defining an effective senior resident. I look forward to completing the project over the next 3 months and using the findings to create a curriculum to help ease the transition from junior to senior resident. This work will be applicable to other programs and hopefully will help all surgeons understand the role of a senior resident in more detail.

Implementing a Robotics Curriculum in Surgery: Lessons learned from the Experts - An Interim Report.

Kristen Jogerst, M.D. 
Research Fellow in MGH Surgery General 
PGY 3
03/01/2020

How does one best train a surgical resident or fellow to become proficient in robotic surgery? What are the best methods for surgical educators to use if they are hoping to teach trainees robotic surgery for the first time? Is simulation necessary? Will this training framework change overtime as general surgery and surgical residencies change?  Does a surgical educator’s frame of reference (based on their own training background) affect how they approach these training questions? To answer all of these questions, my research team, led by Dr. Denise Gee, and I developed a phone interview guide to interview experts within robotic surgery and surgical education. We interviewed experts across academic and community general surgery, gynecological surgery, and urology. We are completing this qualitative investigation using a framework analysis. We received approval from our IRB, achieved group consensus on our refined interview guide after several practice interviews, and have 29 out of our 32 intended interviews done. We have completed interviews with robotic surgical experts and surgical educators across four strata: academic general surgery (10), gynecological surgery (9), Urology (6), and community general surgery (4).

Emerging themes and representative quotes from our team's
preliminary analysis of the semi-structures interviews

While the study is ongoing, our team has already learned a lot about what experts think it takes to build an excellent robotic surgical training program as well as pitfalls they wish they would have knew prior to implementing curricula at their home institutions. Give my research participants are all clinical faculty and surgical experts, many of them are quite busy. I have been extremely appreciative of how willing these experts have been to give of their time. One of the major obstacles to completing qualitative research studies is the same barrier faced by many surgical education projects: time. Logistically many of my phone interviews would get cancelled, delayed, or unexpectedly rescheduled for early morning hours, late nights, or weekends.  However, these scheduling flexibilities have been worth it, as I have been privileged to gain decades worth of surgical education wisdom, all within a few short months. If anyone reading this has ever attempted a qualitative research study with rigorous methodology, I have much more respect for you after the last few months. I also now know the importance of having a backup recorder and how valuable an accurate transcriptionist can be. The rewards and wisdom imparted from the unique constructivist research perspective makes qualitative investigations worthwhile. However, those rewards must be earned and one should expect the research study timeline to take at least double the original timeline estimates. I am thankful for my co-investigator and second transcript coder, Dr. Taylor Coe. Our preliminary analyses and exciting findings would not have emerged without her diligent efforts and late nights of editing and refining our codebook. This project has taught me that when building new curricula or exploring challenging research questions, it is important to consult the experts and surround yourself with the wisdom and experience of other researchers and surgical educators.

Through these hard efforts, we have already learned that building a successful robotic surgery curriculum requires 5 emerging themes: access, investment/ buy-in, relinquishing control, evaluation, and progressive OR integration (Figure 1). We have several more interviews to complete to finalize our framework analysis and compare across the four strata. In addition to completing the final interviews, finishing our coding of the remaining transcripts using our refined codebook, and writing up our framework analysis, I am happy to report our research team

Excited to present our work at the annual meeting for the
Association of Program Directors in Surgery in Seattle
this Spring

will also have the opportunity to present our findings at the Association of Program Directors in Surgery (APDS) annual meeting in Seattle this April (Figure 2). In addition to sharing our lessons learned during Surgical Education Week, our research team plans to submit a final manuscript following the national meeting in May. We are thankful for the support and resources from the Centers of Expertise Medical Education Research Grant and look forward to sharing our final analysis with you later this spring/ summer.