SESSION C WORKSHOPS Friday, April 26, 2013 11:30 AM – 12:00 NOON WC01 Getting your vignette published in JGIM and other journals. A step by step approach. WC02 Teaching Medical Trainees the Practice of Assessment and Counseling of Older Adults on Driving Safety. WC03 The diagnosis-driven physical exam of the knee and shoulder: a hands-on workshop WC04 Building a Therapeutic Alliance with Patients with Chronic Pain Making Chronic Pain Management Less Painful

(for Patients and Providers) WC05 Patient-Centered Care for Recently Released Prisoners WC06 Health Care Reform: Promises and Perils for the General Internist WC07 Building Blocks of High-Performing Primary Care: A Roadmap for Implementing the Share the Care Model WC08 New Models for incorporating continuity into medical education WC09 The Power of Stories to Heal: A Writing Workshop WC10 Resident Professional Development: Creating and Implementing Coaching and Remediation Programs WC11 Get the Most Out of Your Mentoring Experience: Strategies to Become an Active Mentee WC12 Cultivating the Neighborhood for the Patient-Centered Medical Home: Improving Primary Care-Specialty Care

Referrals and Coordination of Care WC13 SIPOCS, VOCS, and Matrixes: a “Lean” Cut of Lean Improvement Tools

WC01 Getting Your Vignette Published in JGIM and Other Journals: A Step by Step Approach Online Registration Title: Getting your vignette published. A step by step approach Coordinator: Chad S. Miller, MD, Tulane University Additional Faculty: Jeff Kohlwes, MD, MPH, University of California, San Francisco; Cindy Lai, MD, University of California, San Francisco; Michael D. Landry, MD, Tulane University; Geraldine E. Menard, MD, Tulane University Session summary Clinical vignettes highlight important aspects of teaching, patient care, and research opportunities. Publication of clinical cases is one measure of scholarly activity. During the manuscript preparation, one can develop and practice skills such as conceptualization of an idea, communication, synthesis of information, and scientific writing. This interactive workshop will provide a hands-on experience during the small group exercise. Outcomes of the workshop are to identify essential elements of clinical vignettes, overcome common obstacles, and assist attendees in preparing an outline of their first draft for publication. Participants will be provided with resource materials and a list of relevant journals accepting case reports. JGIM Editors' Pearls will be highlighted to help improve the likelihood of a successful manuscript submission. JGIM Clinical Vignette Deputy Editors will actively participate in small group sessions and guide the discussion. Measurable Learning Objectives: Understand and recognize the essential elements of a Case Report or Clinical Vignette manuscript Identify strategies and practical suggestions for preparing such manuscripts to enhance the likelihood for publication Identify resources to assist in the writing process Recognize and combat barriers for publication Session Agenda: 5 minutes: Introduction, goals, and objectives 15 minutes: Overview of the writing process, resources, vignette manuscript requirements, and target journals. A

concise presentation on these topics will illustrate key points

40 minutes: Small group exercise - Each small group will use abstracts of submitted clinical vignettes from enrolled participants. Attendees will work with a few clinical vignette submissions, will prepare an outline, and will be provide suggestions on the case by faculty preceptors.

20 minutes: Discussion and summary: Small groups will present their outline and will obtain feedback from the faculty presenters and the audience. The presentations will be limited.

5 minutes: Conclusions 5 minutes: Evaluation

WC02 Teaching Medical Trainees the Practice of Assessment and Counseling of Older Adults on Driving Safety Submitted in Conjunction with: SGIM Geriatrics Interest Group Online Registration Title: Teaching Driving Safety for Elderly Coordinator: Rachel K. Miller, MD, Department of Medicine, University of Pennsylvania Additional Faculty: Jennifer Carnahan, MD, MPH, Medical College of Wisconsin; Danelle Cayea, MD, Johns Hopkins; Steve Huege, MD, University of Pennsylvania; Robert Murden, MD, Ohio State University Session Summary Motor vehicle injuries are a leading cause of injury-related deaths in the older population (persons 65 years and older). Per mile driven, the fatality rate for drivers 85 years and older is nine times higher than the rate for drivers 25 to 69 years old. Physicians play an important role in the safe mobility of their older patients. The AMA encourages physicians to make driver safety a routine part of their medical services. In addition, a recent 2012 New England Journal of Medicine article highlighted the importance of physician warnings in preventing unfit drivers from driving. This is an important public health issue, as the proportion of drivers who are older adults increases medical practitioners will increasingly face patients for whom the matter of balancing patient and public safety on the road versus patient autonomy and freedom is a critical one. Primary care physicians will need to lead the way and be innovators in addressing this complicated issue. However, the issue of driving safety in the setting of cognitive impairment has the potential to cause disagreement and conflict between patient and medical provider. In order to prepare the next generation of medical providers who will care for these older-adults, this session will include resources to teach medical trainees on how to assess driving impairment and how to discuss concerns related to driving in older adult patients. This will include discussion of “teachable moments” during informal teaching interactions such as clinic precepting and ward rounding. Participants will have the opportunity to discuss challenges and successes in teaching driving assessment and counseling. Workshop leaders will provide resources for “on the fly” teaching and resources and examples of successful formal curricula. Measurable Learning Objectives Identify teachable moments for teaching trainees assessment of the older driver Describe methodology to provide teaching for trainees in the practice of assessment and counseling of older adults

with cognitive impairment Describe resources that can be used when teaching formally and "on-the-fly" about assessment and counseling of

the older driver for medical trainees to use with their patients in assessment and counseling Session Agenda: 5 minutes: Introductions/objectives 5 minutes: Ice breaker/warm up-divide into dyads/triads and share what got you interested in this workshop-

"When do you think about a patient needing a driving assessment?" When do you teach this issue to your trainees? 10 minutes Didactic on methods/resources for teaching assessment - include video clip 30 minutes Facilitated Small group discussion re: teaching assessment, have handouts, resources available, could discuss how we would practically use these, successes and challenges, etc. 10 minutes: Brief didactic on methods/resources for teaching counseling (video with patient/family member) 20 minutes Facilitated Small group discussion re: teaching counseling, teaching how to manage the family, have

handouts, resources available, could discuss how we would practically use these, successes and challenges, etc (20 min)

10 minutes: Wrap-up/Evaluation

WC03 The Diagnosis-Driven Physical Exam of the Knee and Shoulder: A Hands-On Workshop Online Registration Title: Physical exam of the knee and shoulder: a hands-on workshop Coordinator: Carlin Senter, MD, University of California San Francisco Additional Faculty: Veronica M. Jow, MD, University of California Berkeley; Natalie Voskanian, MD, University of California, San Diego Session Summary We are three junior faculty members from three different institutions. We are each board-certified in Internal Medicine and fellowship-trained in Primary Care Sports Medicine. Dr. Voskanian practices primary care sports medicine at the University of California San Diego. Dr. Jow is a primary care physician in student health and a team physician at the University of California, Berkeley. Dr. Senter practices primary care internal medicine and primary care sports medicine at the University of California San Francisco. As local leaders in primary care sports medicine, we hope to bring our expertise to a broader group of generalists. Musculoskeletal diseases are the second-most common reason people seek medical care in the United States and are becoming more prevalent with time (Freedman and Bernstein, 1998; Nguyen, 2011). Musculoskeletal education has been under-emphasized in medical education, resulting in low confidence and competence in physicians practicing musculoskeletal medicine (Clawson, 2001; Freedman and Bernstein, 1998 and 2002; Lynch, 2006). It is critical that we offer primary care providers opportunities to develop their musculoskeletal exam skills in order for them to better care for their patients’ musculoskeletal problems. It is important to teach generalists musculoskeletal medicine so that they can successfully teach these skills to medical students and residents, who will become the generalists of the future. To address these needs we propose a musculoskeletal workshop for the 36th Annual Society of General Internal Medicine meeting. The workshop will appeal to students, residents, fellows, and attendings who have beginner to intermediate skills in physical examination of the knee and shoulder. We will use a case-based approach to demonstrate the knee and shoulder examinations, supported by video that demonstrates each exam maneuver. This will be followed by small group hands-on exam practice. With three faculty instructors, all attendees will have a chance to be observed performing the knee and shoulder exam, and to receive direct feedback on their skills. Attendees will also have ample time to ask questions of the faculty, regarding exam techniques or treatment options in specific patient cases. References

1. Clawson DK et al. It’s past time to reform the musculoskeletal curriculum. Academic Medicine. 2001;76(7)709-10.

2. Freedman KB, Bernstein J. Educational deficiencies in musculoskeletal medicine. J Bone Joint Surg Am. 2002 Apr;84-A(4):604-8.

3. Freedman KB, Bernstein J. The adequacy of medical school education in musculoskeletal medicine. J Bone Joint Surg Am. 1998 Oct;80(10):1421-7.

4. Lynch JR et al. Important demographic variables impact the musculoskeletal knowledge and confidence of academic primary care physicians. J Bone Joint Surg Am. 2006 Jul;88(7):1589-95.

5. Nguyen US et al. Increasing prevalence of knee pain and symptomatic knee osteoarthritis: survey and cohort data. Ann Intern Med. 2011 Dec 6;155(11):725-32.

Measurable Learning Objectives: 1. Explain the organizational scheme of any musculoskeletal examination 2. Demonstrate how to examine the knee, including proper techniques to inspect, palpate, measure range of

motion, and use special tests, while putting into context the differential diagnoses of knee pain during each exam maneuver

3. Demonstrate how to examine the shoulder, including proper techniques to inspect, palpate, measure range of motion, and use special tests, while putting into context the differential diagnoses of shoulder pain during each maneuver.

Session Agenda: 45 minutes: Knee

15 minutes: We will explain the organizational scheme for the musculoskeletal exam and teach a step-by-step physical examination of the knee. Clinical cases will be used to highlight the utility of each exam maneuver. Video will be used to illustrate the physical exam tests.

30 minutes: Small group physical exam practice. The group will break into pairs or small groups of 6-8 around tables (size of small groups can vary depending on size of workshop). The 3 faculty will circulate, reviewing the step-by-step approach to the physical exam of the knee. We will also put the exam into context based on the examiner’s differential diagnosis for a given case. Instructors will answer questions posed by the attendees in small group.

45 minutes: Shoulder 15 minutes: We will review the organizations scheme for the musculoskeletal exam, and teach a step-by-step physical

examination of the shoulder. Clinical cases will be used to highlight the utility of each exam maneuver. Video will be used to illustrate the physical exam tests.

30 minutes: We will again break into small groups to examine each other’s shoulders. Faculty will circulate to teach the small groups. We will put the exam into context based on the examiner’s differential diagnosis for a given case. Instructors will answer questions posed by the attendees in small group.

WC04 Building a Therapeutic Alliance with Patients with Chronic Pain – Making Chronic Pain Management Less Painful (for Patients and Providers) Submitted in Conjunction with: SGIM Pain Interest Group Online Registration Title: Building a Therapeutic Alliance with Patients with Chronic Pain Coordinator: William Becker, MD, VA Connecticut Healthcare System Additional Faculty: Matthew J. Bair, MD, Indiana University School of Medicine; Erin E. Krebs, MD, MPH, Minneapolis VA Healthcare System; Joanna L. Starrels, MD, MS, Albert Einstein College of Medicine; Daniel G. Tobin, MD, Yale University Session Summary Generalists treat the vast majority of patients with chronic pain. Despite the ubiquity of chronic pain in general medical practices, many physicians lack confidence and satisfaction with chronic pain management. As such, the overall learning objective of this workshop is to train participants in skills that will improve their confidence in and satisfaction with treatment of chronic pain, and ultimately improve their therapeutic alliance with patients. Expert faculty will lead participants through a series of interactive cases illustrating key concepts. The workshop will contain role-play activities so participants can practice skills described below. The learning objectives are as follows: (1) Learn the components of a shared-decision making approach to management of chronic pain. Patient and provider

frustration in chronic pain management comes from a lack of balance in control over treatment decisions. Patients may feel excluded from decisions or, conversely, physicians may believe that patients are overly passive or overly aggressive. Shared decision-making requires that the plan and goals of care be (a) transparent, (b) understandable to the patient, (c) mutually agreed upon, and (d) revisited frequently. This approach will be described in a didactic presentation, modeled in a vignette, and discussed as a group.

(2) Learn techniques for managing goals and expectations of chronic pain management. Patients and providers sometimes expect that chronic pain will resolve, but pain continues in most cases, resulting in frustration. Skills we will emphasize include: (a) setting realistic goals that target function (e.g., completing activities of daily living), (b) monitoring frequently for progress, and (c) employing a multimodal approach to pain management that targets behavioral, pharmacological and physical-therapy based treatments. These skills will be described in a didactic presentation, modeled in a vignette, and discussed as a group.

(3) Practice shared decision-making and goal-management techniques to opioid treatment. Opioid treatment is an area of particular frustration for many providers; when embarked upon with clear discussion of potential risks and benefits as well as goals and expectations, data show an improvement in provider satisfaction. Participants will role-play a clinical encounter in which opioid initiation is considered. Discussion of the strengths, weaknesses, and alternate approaches will be moderated by one of the faculty members.

(4) Practice managing conflict in difficult conversations about opioids. Physicians’ desire to avoid anticipated conflict may lead to continuation of opioids in unsafe situations or reluctance to start them in the first place. Participants will role-play a clinical encounter in which the provider has decided that opioids must be discontinued. Faculty members will moderate.

Measurable Learning Objectives Learn the essential components of a shared-decision making approach to management of chronic pain Learn techniques for managing goals and expectations of chronic pain management Practice shared decision-making and goal-management techniques to opioid treatment. Practice managing conflict in difficult conversations about opioids Session Agenda: 5 minutes Introduction: Faculty members/facilitators will introduce themselves to participants and review the

schedule for the workshop. 10 minutes: Didactic presentation: Using power point slides in a large group setting, facilitators will:

Review data on physician knowledge, skills and attitudes related to management of chronic pain. Describe the key elements of shared-decision making with a focus on relevance to management of

chronic pain. Review techniques for managing goals and expectations in treatment of chronic pain.

20 minutes: Case vignette, video presentation, large group discussion The vignette will be a new patient visit of a 50 year old man with low back pain who has recently

changed practices after losing his health insurance. Faculty will read the patient’s history and the video will begin at the point in the visit where the patient requests opioids for treatment of pain. The provider response will feature some of the common pitfalls in communicating with patients about chronic pain and is designed to resonate with participants and spur discussion. After conclusion of the video, facilitators will invite participants to share with the group their reactions to it. This will be followed by a second video with the same case vignette where the provider implements and models a shared decision-making approach. Participants will then be invited to comment on the relative strengths and weaknesses of this approach.

20 minutes: Case vignette, video presentation, large group discussion. The vignette will feature a 45 year old woman with chronic neck pain coming for a change of provider

visit as the patient felt the previous provider was doing “nothing to help me.” Faculty will read the relevant history; the video will begin at the point in the visit where the provider is discussing treatment options. The provider response will feature common pitfalls in discussing treatment options (e.g. focusing only on pharmacotherapy, accepting the patient’s goal of being “pain free” and allowing the patient to place locus of control on the provider). After conclusion of the video, facilitators will invite participants to share with the group their reactions to it. This will be followed by a second video with the same patient where the provider implements and models appropriate goal setting and expectations for treatment. Participants will then be invited to comment on the relative strengths and weaknesses of this approach.

30 minutes Participant Role-play Participants will be divided into five small groups in which they will be given two case vignettes.

Participants will engage in role-play exercises in which one “provider” and one “patient” from each small group will demonstrate a clinical encounter in which (1) initiation of opioids is considered and (2) the provider has decided that opioids must be discontinued. Discussion of the strengths, weaknesses, and alternate approaches among participants in each small group will be moderated by one of the faculty members.

5 minutes Wrap up and session evaluation Facilitators will summarize the discussions they observed and the learning objectives of the workshop

and elicit any remaining questions or comments from the participants.

WC05 Patient-Centered Care for Recently Released Prisoners Submitted in Conjunction with: SGIM Substance Abuse and Criminal Justice Interest Groups Online Registration Title: Patient-Centered Care for Recently Released Prisoners Coordinator: Sarah E. Wakeman, MD, Department of Medicine, Harvard Medical School Additional Faculty: Ingrid A. Binswanger, MD, MPH, University of Colorado School of Medicine; Aaron Fox, MD, Albert Einstein College of Medicine; Alexander Y. Walley, MD, Boston University School of Medicine; Emily Wang, MD, MAS, Yale University School of Medicine

Session Summary Ten Million Americans are incarcerated each year, 95% of whom will eventually be released to the community. (1) The annual incidence of new incarceration is six times higher than the incidence of all new cancer diagnoses. (2) With one in thirty-one Americans under some form of correctional control, incarceration has become a shared life experience for many of our patients. The post-release period presents extraordinary risks to individuals returning home from prison. In the two weeks after release, former inmates are 129 times more likely to die from a drug overdose and twelve times more likely to die of any cause. (3) Issues of insurance coverage, medication access, as well as the competing priorities of housing, fractured personal relationships, and untreated addiction and mental illness pose tremendous challenges. (1) The focus of this workshop will be on how to provide patient-centered medical care during this challenging time of transitions. The workshop itself will be patient-centered, based on a small group format with individuals with a history of incarceration joining each group to offer unique perspectives on challenges faced following release from prison and opportunities for optimizing care. The session will begin with a brief overview of incarceration and medicine. This will highlight the epidemiology of incarceration; the dramatic overrepresentation of the poor, the mentally ill, the addicted, and people of color; medical topics of particular importance within corrections, including substance use disorders and opiate replacement therapy in corrections, mental illness and the impact of conditions of confinement, and infectious diseases; and the risks during the transitional period following release from prison. The remainder of the session will be a small group format. Each group will have an individual with a history of incarceration and a physician moderator from the workshop joining the session participants. Group members will have a list of discussion questions addressing the following topics: Models of transitional care; systems, physician, and patient barriers that currently limit optimal care; relationship-building between physicians and patients with a history of incarceration; and the role of academic medicine and trainee involvement in the care for this population.

1. Rich JD, Wakeman SE, Dickman SL. Medicine and the epidemic of incarceration in the United States. N Engl J Med. 2011 Jun 2;364(22):2081-3.

2. Howlader N, Noone AM, Krapcho M, Neyman N, Aminou R, Altekruse SF, Kosary CL, Ruhl J, Tatalovich Z, Cho H, Mariotto A, Eisner MP, Lewis DR, Chen HS, Feuer EJ, Cronin KA (eds). SEER Cancer Statistics Review, 1975-2009 (Vintage 2009 Populations), National Cancer Institute. Bethesda, MD, http://seer.cancer.gov/csr/1975_2009_pops09/, based on November 2011 SEER data submission, posted to the SEER web site, April 2012.

3. Binswanger IA, Stern MF, Deyo RA, et al. Release from prison -- a high risk of death for former inmates. N Engl J Med 2007;356:157-165

Measurable Learning Objectives: 1) Understand the current epidemic of mass incarceration and the risks during the post-release period particularly

for people with addiction, mental illness and other chronic diseases, 1. Describe an ideal model of care for recently released prisoners, 2) Understand the systemic, individual, and physician barriers to care for this population 3) Develop a patient-centered approach to caring for patients with a history of incarceration

Session Agenda: 15 minutes Introduction:

Overview of incarceration and Medicine Describe the current U.S. epidemic of incarceration Discuss the root causes including the “War on Drugs” and the deinstitutionalization of the mentally

ill Discuss racial disparities Overview of the high burden of disease among this population, including infectious diseases,

substance use disorders, mental illness, and chronic diseases Describe the risks following release, including overdose

45 minutes Small groups: Each group has at least one patient and one physician moderator

Small group questions: 1) How can physicians and the health system provide good care for people transitioning from inside to

outside? 2) What addressable barriers exist for physicians and the health system limit optimal post-release

care? Ex: Legislation preventing Naloxone distribution; Limited options for opioid replacement therapy; Medicaid termination; Physician lack of awareness; lack of access to primary care.

3) Should physicians ask about history of incarceration in a visit and if so, how? 4) What addressable barriers do individuals face returning from prison and how can physicians and

health systems assist reducing those barriers? Ex: Competing priorities; Lack of awareness about health issues; Fear of stigma from providers.

(5) What role can academic medicine play in helping improve care for former and current prisoners? How can trainees be involved responsibly?

20 minutes Group discussion and questions: Groups report back on their discussions 10 minutes Session Evaluation

WC06 Health Care Reform: Promises and Perils for the General Internist Submitted in Conjunction with: SGIM Health Policy Committee Online Registration Title: Health Care Reform for GIM Coordinator: Mark D. Schwartz, MD, New York University Additional Faculty: Angela Jackson, MD, Boston University; Scott Joy, MD, University of Colorado; Cara Litvin, MD, MS, Medical University of South Carolina; Gary Rosenthal, MD, University of Iowa Session Summary At no time in the recent past has the health care policy arena been so turbulent, and the future of care delivery, research, and training so uncertain. SGIM members contribute and lead efforts in these domains nationally. As implementation of health care reform moves to the states, informed and activated generalists will be essential to ensuring that the changes and innovations in the Affordable Care Act are operationalized wisely. The SGIM Health Policy Committee will present an overview of the leading policy issues related to improving patient care, strengthening education and training, and promoting research in general internal medicine. We will provide participants with stories of impact of SGIM's advocacy that will make these issues relevant to physicians' lives at home. There will also be an opportunity to develop advocacy skills. Measurable Learning Objectives: 1. Provide an update on current issues related to clinical practice, research and education likely to affect general

internists and their patients 2. Discuss potential benefits and threats to continued health care reform 3. Discuss opportunities for SGIM members to play a role in advocacy for issues related to general internal medicine Session Agenda: 5 min Overview of the current status of health care reform and critical health policy issues related to general internal

medicine. 10 min Generalist Clinical Practice Policy (6 min presentation + 4 min Q&A) 10 min Medical Education/Training Policy (6 min presentation + 4 min Q&A) 10 min Generalist Research Policy (6 min presentation + 4 min Q&A) 10 min Advocacy Skills and Opportunities for Busy General Internists 10 min Overview 20 min Skills Practice 15 min General Discussion 5 min Evaluation

WC07 Building Blocks of High-Performing Primary Care: A Roadmap for Implementing the Share the Care Model Online Registration Title: Share the Care: Building Blocks of Primary Care Transformation Coordinator: Reena Gupta, MD, Assistant Professor of Medicine, General Internal Medicine, San Francisco General Hospital, University of California, San Francisco Additional Faculty: Tom Bodenheimer, MD, University of California, San Francisco; Amireh Ghorob, MPH, University of California, San Francisco Session Summary What does the future of primary care look like? As health care costs sky rocket and the aging population requires ongoing care for multiple chronic conditions, it is clear that the traditional model of primary care is not working. Innovative practices nationwide have helped to shape a clear vision for a new primary care practice model to improve health care quality, patient experience, and reduce costs. The 10 building blocks of primary care transformation were derived from numerous site visits to high-performing primary care practices across the country to understand how these practices are achieving the creation of successful patient-centered medical homes. The unanimity with which these practices employ 10 consistent building block principles suggests that there is one basic model, with individual variation -- the Share the Care Model -- for primary care excellence. . We will discuss the evidence base and rationale for the Share the Care Model, developed by the Center for Excellence in Primary Care at UCSF from site visits and extensive interviews with leadership, staff and providers at high-performing primary care practices nationwide. We will review the building blocks of the Share the Care Model and recommended order of implementation, including: data-driven improvement, empanelment and panel size management, patient-driven access, continuity of care with the care team, and population management. Participants will examine details of each of the 10 building blocks of the Share the Care Model, meant to provide practical tools for implementation of primary care transformation in their home institutions. Participants will then compare and contrast high performing practices with traditional practices utilizing the principles of Share the Care. Evidence has shown that robust practice facilitation can support transformation into high-performing practices. We will model elements of practice facilitation by engaging participants in redesigning care team roles and drafting standing orders that empower team RNs and medical assistants with expanded roles, thereby increasing the overall capacity of the practice. We will utilize interactive, small groups for participants to actively engage in the content and come away with specific skills to implement the building blocks in their home primary care practices.

Ghorob A and Bodenheimer T. Sharing the Care to Improve Access to Primary Care. New England Journal of Medicine 2012; 366:1955-1957 Willard R and Bodenheimer T. The Building Blocks of High-Performing Primary Care: Lessons from the Field. California Healthcare Foundation report, April 2012 (www.chcf.org)

Measurable Learning Objectives: By the end of the workshop, participants will be able to: 1) Identify the 10 building blocks of the Share the Care model to transform traditional primary care practices into high-

performing practices 2) Identify barriers and propose solutions to overcome barriers to implementing the building blocks in their home

practices 3) Describe at least 2 specific approaches to redesign team member roles and functions to create multidisciplinary

primary care teams 4) Write standing orders to empower nurses and medical assistants to work at the top of their licensure to share the

care in a team-based system Session Agenda: 5 min Welcome and brief introductions (Dr. Reena Gupta) 15 min Introduction to the 10 Building Blocks of High-Performing Primary Care: the Evidence Base and Rationale

for the Share the Care Model (Dr. Tom Bodenheimer)

25 min Interactive small group session: “The Building Blocks in Practice.” Participants will examine the building blocks in traditional versus transformed primary care practices and compare this to their local institutions. (Dr. Reena Gupta)

25 min Interactive small group session: “Share the Care. Re-defining team member roles in high-functioning primary care teams: An exercise in how to create standing orders to expand team RN and medical assistant roles.” (Dr. Tom Bodenheimer and Amireh Ghorob)

10 min Lessons from small group discussions and closing remarks 10 min Session evaluation

WC08 New Models for Incorporating Continuity into Medical Education Submitted in Conjunction with: Learning Communities Institute Online Registration Title: New Models for incorporating continuity into medical education Coordinator: David S. Hatem, MD, Internal Medicine, University of Massachusetts Medical School Additional Faculty: Lars Osterberg, MD, MPH, Stanford University School of Medicine; Robert Shochet, MD, Johns Hopkins University, Johns Hopkins Univeristy School of Medicine Session summary: Increased fragmentation of clinical care combined with competition between clinical productivity demands, research, and education threatens the quality of medical education and the learning environment. Continuity of faculty-student interactions is increasingly being promoted as a foundational principle to counter these forces in several new medical education initiatives. Learning Communities are one such innovation. Continuity in Learning Communities entails faculty supervision, role modeling and mentoring and these methods are promoted as a way to foster student skills, student wellness and potentially counter some of the influence of the hidden curriculum. The importance of longitudinal faculty-student relationships becomes more apparent as assessments move toward a competency based system. The movement toward continuity in faculty supervision with dedicated role models creates a supportive learning environment for students enhancing the delivery of curriculum and promoting more effective student support. This workshop will discuss Learning Communities as one example of educational continuity, describing the value and challenges of leaders own models. Small group breakouts will allow participants to consider how to incorporate continuity into their educational settings from the medical student to the resident level Measurable Learning Objectives: Discuss continuity in medical education and its applications to Learning Communities Discuss benefits and barriers to implementing continuity into educational activities Discuss other innovative methods to incorporate continuity into education initiatives Apply lessons learned to educational settings back at participant's home institution Session Agenda 10 minutes Introduction of the session, introduction of speakers, and goal setting 10 minutes 20 minutes Brief Presentation by Workshop Leaders 20 minutes

a. Models of Learning Communities and continuity at 3 institutions b. Other Models of continuity (longitudinal clerkships, long blocks) c. Continuity across the continuum of medical education

40 minutes Small Group Breakouts Applying continuity in educational settings Unit of continuity (learner-patient, learner-teacher, learner-learner, learner-curriculum) ii. “Dose” of continuity iii. Expected Outcomes

10 minutes Report back from Small Group discussions: lessons learned, applications to home 10 minutes Evaluation and Wrap-Up

WC09 The Power of Stories to Heal: A Writing Workshop Online Registration Title: The Power of Stories to Heal: A Writing Workshop Coordinator: Rachel Swigris, DO, University of Colorado Additional Faculty: Jessica Campbell, MD, University of Colorado; Anjali Dhurandhar, MD, University of Colorado; Therese Jones, PhD, University of Colorado; Douglas Reifler, MD, Rosalind Franklin University of Medicine and Science Session Summary Physician burnout is a major factor that impacts healthcare. Studies have demonstrated that developing self- awareness skills may help us as providers to be more engaged with our work, may promote empathy, enhance self-care, and help to prevent burnout. Reflective writing has been shown to increase self-awareness and mindfulness. This helps to decrease burnout and cynicism and may lead to better patient care. Narrative medicine is the study of narrative or stories as a foundation for enhancing the relationships amongst patients, doctors, nurses, case managers, and the many other caregivers involved in the clinical encounter. It is a cost-effective and evidence-based method to provide health care professionals with the skills needed to respond to the challenges of medicine. By strengthening clinical practice with the ability to recognize, absorb, interpret, and be moved by stories of illness, narrative training enables physicians to comprehend patients’ experiences and to understand what they themselves experience as clinicians. Narrative medicine can bring meaning to the practice of medicine, mitigate burnout and translate into scholarship. Specifically, narrative medicine allows for self-reflection, clarification of personal values and priorities, contemplation on the patient experience and uncovers unrecognized feelings and attitudes. Narrative medicine offers the opportunity for telling and witnessing that reveals the psychological, emotional and sociocultural context that lie within the deepest roots of illness. This equips providers with tools to heal if not cure. We will describe the innovative program that we implemented at our institution named The Hergott Heart of Medicine writing workshop series. Our aim is to help medical students, residents and faculty build the necessary skills to develop narrative competence by offering the opportunity to write stories and to share them in small group discussions that encourage appreciative inquiry and attentive listening. In addition, this serves as a pathway for scholarship as we help participants publish their work locally and nationally. Then our SGIM workshop will provide a similar writing workshop experience. Participants will be given time to write about an experience in which they personally felt healed by an encounter or a relationship in their teaching or practice of medicine. Then, on a voluntary basis, participants may share their stories in small groups. Through these discussions, participants may discover new insights about their stories. Afterwards, participants will reconvene to discuss methods of implementing this exercise or a similar program at their own institutions. Reflecting and sharing in this genuine manner may create a sense of community and purpose, and ultimately, may help to create healing connections for us and for our patients. Measurable Learning Objectives: Participants will write about an experience of feeling personally healed by a patient encounter or a relationship in

the teaching or practice of medicine Participants will identify how reflective writing promotes a deeper understanding of the practice of medicine Participants will share narratives in small groups and discuss how to implement writing workshops at their own

institutions. Participants will examine the usefulness of writing and sharing narratives for medical trainees and practicing

physicians. Session Agenda: 10 minutes Introduction: The Hergott Heart of Medicine Project Dr. Rachel Swigris, Dr. Jessica Campbell 15 minutes Usefulness of Writing Narratives about Personal Experiences Dr. Anjali Dhurandhar, Dr. Douglas Reifler, Dr. Therese Jones 20 minutes Writing exercise 25 minutes Break into Small Groups and Discuss Stories 15 minutes Rejoin Large Group to Share Ideas and Summarize Ideas Learned in Smaller Groups 5 minutes: Session evaluations

WC10 Resident Professional Development: Creating and Implementing Coaching and Remediation Programs Online Registration Title: Creating and Implementing Coaching and Remediation Programs Coordinator: Kerri L. Palamara, MD, Associate Program Director, Medicine, Massachusetts General Hospital Additional Faculty: Dominique Cosco, MD, Emory University School of Medicine Session Summary With the transition to the Next Accreditation System, milestone-based education and work hour changes, our time with residents is limited, and our need to account for their professional development throughout their training is greater than ever. Many programs are not structured to closely coach all residents throughout their growth as a physician and provide the necessary authentic career development for milestone achievement. While residents who are struggling with performance and professional issues are given close attention, they are often identified too late and receive ineffective remediation. Additionally, residents who are meeting expectations have not historically received ongoing coaching to promote their professional development and pursuit of excellence. There have been many workshops focused on resident remediation programs, but rarely do they afford participants the time to brainstorm about the unique challenges they face in implementing programmatic changes at their institution and allow them to discuss strategies for successfully overcoming those challenges. Additionally, this workshop will provide tools to develop comprehensive behaviorally based remediation plans tailored to the internal medicine core competencies. The information and techniques can be adapted to the internal medicine milestones. The workshop will begin with a review of the successful Core Competency Committee at Emory University, in which their approach to and struggles with developing the program, their committee structure, and the Weinerth Five-Step Method of Remediation will be reviewed. Specifically, we will illustrate our method of organizing, implementing, and documenting unique and individualized remediation plans for residents that are competency based. We will share de-identified cases of remediation plans to demonstrate the successes and pitfalls in the remediation process. Then, the audience will work individually, considering their current remediation process and areas for improvement or change. They will then break into small groups to share common struggles and brainstorm potential methods for successfully overcoming those challenges. Next, the Massachusetts General Hospital’s Professional Development Coaching Program will be reviewed, including an overview on the role of coaching in residency education, the difference between coaching and mentoring, and the use of positive psychology to coach residents throughout their training. The audience will discuss ways in which coaching can be incorporated into their programs, and participate in a coaching exercise where they will coach and be coached. Measurable Learning Objectives Identify the main principles of remediation, barriers to designing and implementing a remediation or coaching

program that exist at their institution, available resources and strategies for implementing a successful remediation program

Design or adjust a remediation program for their institution based on the needs and the goals of their learners Describe the difference between coaching and mentoring, and identify ways to incorporate resident coaching at

their institution. Session Agenda: 10 minutes Introduction and Overview 20 minutes Review of Emory Core Competency Committee and Remediation Cases 20 minutes Individual and Small Group Breakout 15 minutes Review of MGH Professional Development Coaching Program 10 minutes Coaching Exercises 15 minutes Discussion

WC11 Get the Most Out of Your Mentoring Experience: Strategies to Become an Active Mentee Online Registration Title: Tools and Strategies to Become an Active Mentee Coordinator: Analia Castiglioni, MD, Associate Professor, University of Central Florida College of Medicine Additional Faculty: Rachel Bonnema, MD, MS, University of Nebraska Medical Center; Brita Roy, MD, MPH, MS, University of Alabama, Birmingham; Abby Spencer, MD, MS, FACP, Temple University School of Medicine; Lisa L. Willett, MD, University of Alabama, Birmingham Session Summary Effective mentoring is one of the most important determinants of success in academic medicine. Mentoring relationships develop spontaneously, are formally arranged within institutions, and are offered to attendees at national academic meetings. Regardless of the structure and duration, a successful mentoring relationship requires that the mentee is an active participant, taking ownership of the interaction and directing his/her goals. Data from a national academic medical meeting, assessing their one-on-one mentoring program, shows that 90% of mentors expected their mentees to come prepared to their meeting, while the majority of mentees reported lack of training or faculty development on how to be a good mentee. We designed this workshop to provide trainees and junior faculty with the necessary tools and strategies to prepare themselves for future mentoring relationships. Learners will participate in an individual reflective exercise and small group discussions; they will be introduced to the concept of “managing-up” as an effective technique to facilitate a successful mentoring relationship. This workshop will benefit potential mentees at all levels of training (students, residents, chief residents, fellows, junior faculty), as well as those who mentor them. Learners will be able to take home their own, personalized, “how to be a good mentee” toolkit Measurable Learning Objectives Understand the importance of being an active, responsible mentee to maximize the mentoring relationship Review the concept of ‘managing-up’ to promote effective, successful mentoring Learn tools and strategies to prepare mentees for future mentoring interactions Session Agenda: 5 minutes: Introduction, goals, and objectives 10 minutes Didactic Presentation: mentoring, importance of being a good mentee, introduction to the concept of

‘managing up’ 10 minutes Individual Reflective Exercise: define learner’s academic and personal goals, mentoring needs and

necessary steps to achieve them (10 min) 30 minutes Small Group Exercise: Participants will share their exercise responses and personal experiences as mentees and mentors.

Facilitators will provide tools and clear strategies to become an active mentee, role-play of ‘managing up’ technique

30 minutes Large Group Discussion: Sharing of small groups’ discussions/experiences/strategies 5 minutes Conclusions and Evaluations

WC12 Cultivating the Neighborhood for the Patient-Centered Medical Home: Improving Primary Care-Specialty Care Referrals and Coordination of Care Online Registration Title: Enhancing PCP – Specialist Coordination Coordinator: Nathaniel Gleason, MD, Assistant Professor of Clinical Medicine, Department of Medicine, UCSF Additional Faculty: Ralph Gonzales, MD, MSPH, University of California, San Francisco; Bruce E. Landon, MD, MBA, Harvard Medical School; Thomas D. Sequist, MD, MPH, Harvard Vanguard Medical Associates Session summary (limit: 3,000 characters, including spaces) (Workshop): The advent of Patient-Centered Medical Homes (PCMH) has created renewed enthusiasm for primary care practice in the US. As practices strive to transform to PCMHs, most attention has been directed towards adoption and use of enhanced electronic health record (EHR) functionality, population management strategies, and the incorporation of teams and tools to promote patient engagement. The logical next step in this transformation is to recognize that effective and efficient health care for patients often requires engagement of specialists and other health professionals, i.e. the PCMH-Neighborhood. In particular, PCMHs will be required to manage and coordinate all the care delivered to patients as they assume financial responsibility for the total costs of care delivered to their patients. In this Workshop, we will describe the epidemiology of referrals in the US, and share a conceptual framework for understanding how PCMHs can work with their specialist colleagues. The major areas that we will cover include:

1. Current patterns of specialty referrals, and mapping the referral process. We will describe an analysis of EHR data to create a detailed "map" of specialty referrals using detailed information on clinical diagnoses to understand the scope of primary care demand for specialty services as part of a program to develop a more value-oriented approach to meeting primary care needs for specialist input.

2. Improving communication between practices, including care coordination agreements and repatriation principles. We will describe collaborative agreements across a wide spectrum of specialty services that define the most efficient methods of co-managing our patient population, including the delivery of preventive and chronic care services.

3. Improving the quality of the referral, including referral guidelines and templates. We will describe “Smart Referral” templates that can be used by primary care physicians at the point of referral. These templates have been developed by specialists and communicate the appropriate clinical criteria and testing that are recommended to make the first specialty visit most efficient.

4. eConsults as a strategy to curb excess demand for and improve access to specialty care. We will describe our experience using eConsults that provide 72 hour specialist advice for patients that do not require an in-office encounter. Specialists and primary care physicians each receive 0.5 wRVU payment and/or credit in this pilot program.

Measurable Learning Objectives: To describe distinct co-management relationship types between primary care and specialists To identify several strategies for minimizing unnecessary referrals to specialty care To describe several strategies to enhance communication and co-management between primary care and specialty

care. Session Agenda: 1. Introductions 2. Background and Significance of Rising Specialty Care visits 3. The PCMH-Neighborhood Principles 4. The Primary Care-Specialty Care Referral Process--a Conceptual Framework and Mapping 5. Interventions/Approaches

a. Care Coordination Agreements b. Referral Templates b. eConsults c. Co-Management Case Conferences

WC13 SIPOCS, VOCS, and Matrixes: A “Lean” Cut of Lean Improvement Tools Category: Quality of Care/Patient Safety Online Registration Title: A “Lean” Cut of LEAN Coordinator: Katherine M. McKinney, MD, Lexington VA Medical Center Additional Faculty: LeeAnn M. Cox, MD, Indiana University School of Medicine; Heather Woodward-Hagg, MS, VA Center for Applied Systems Engineering (VA-CASE), Richard L Roudebush VA Medical Center Session Summary This workshop will augment an internist’s natural affinity for leading clinical quality improvement through providing a practical introduction to key process improvement methodologies and tools. The learner will develop experiential knowledge in Lean quality improvement methodology via hands on use of process improvement tools applied through interactive case studies and small group exercises. The use of quality improvement tools in healthcare organizations has expanded in recent years. Both the methods and core principles of Lean and Six Sigma have been applied within healthcare, borrowing from fields including business and manufacturing. Process improvement strategies such as the “PDSA” cycle are often applied to projects in the clinical arena. In addition, utilizing quality improvement methods within the residency training environment is integral satisfying the ACGME requirements to mentor practice based learning improvement (PBLI). However, both medical educators and trainees are frequently unprepared to apply quality improvement tools to daily clinical practice due to lack of familiarity with improvement philosophies and little to no practical experience utilizing common improvement tools. This presentation will introduce the learner to core principles, methodology, and tools of LEAN and Six Sigma. Each improvement philosophy will be compared and contrasted through use of case studies emphasizing practical application of concepts. The majority of the session will engage the learner through small group exercises to encourage “hands on” application of concepts. Participants will be prompted to identify topics from their clinical practice or residency training experience where they have identified a quality improvement need. These participant selected topics will then be utilized throughout the workshop to provide step-by-step application of Lean tools to each phase of a process improvement project. Discrete small group exercises will introduce techniques for appropriately scoping QI projects via crafting project aim statements, constructing voice of the customer surveys (VOCS), and identifying critical process stakeholders via a construction of a SIPOCS matrix. Faculty will then guide participants through current and future state flow mapping with focus on identification of value versus non-value process steps. Opportunity prioritization tools including affinity diagramming, risk/frequency matrixes, and multi-voting will be utilized in hands on exercises with faculty discussion regarding deciding upon a qualitative versus quantitative measurement strategy. Finally, solution prioritization exercises and implementation planning will address issues influencing the sustainability of QI projects. Throughout the workshop, exercises and application of concepts will be tailored to engage clinicians, medical educators, and trainees with emphasis on effective leadership in quality improvement. Measurable Learning Objectives: Outline the core principles of Lean and Six Sigma Introduce high yield process improvement tools Apply Lean tools to participant chosen quality improvement issues Establish a strategy for choosing among process improvement tools Session Agenda: 5 minutes Learner/faculty backgrounds (5 minutes) Learners will be given the opportunity to share their background and experience utilizing process improvement tools with faculty. Faculty will introduce themselves 15 minutes Introduction to Lean and SixSigma

The philosophies of Lean and Six Sigma will be compared and contrasted. Faculty will outline core concepts through a brief power-point presentation in combination with audience participation and case based examples.

15 minutes Small group exercise #1: current state mapping Participants will work in small groups to flow map a self-selected clinical process improvement need and identify value versus non-value steps. Voice of the customer surveys and SIPOCS matrix will be discussed and utilized for flow mapping. The activity will be debriefed via small and large group discussion.

15 minutes High yield process improvement tools Faculty will provide a practical overview of tools and methods utilized in designing robust process improvement. Focus will be upon human factors design, visual controls, and workflow optimization and rationale for use of specific methods and tools.

20 minutes Small group exercise #2: opportunity prioritization and future state mapping Participants will break into small groups again and utilize high yield tools including an effort/impact grid and multi-voting to analyze their original clinical process flow map. Faculty will facilitate small group work and provide mentorship as participants design a future state process map. Faculty will solicit feedback and stimulate small group discussions regarding ease of use and troubleshooting tools.

10 minutes Large group debriefing and discussion Each small group will provide a brief commentary during large group discussion regarding any difficulty encountered during the exercise and utility of tools. Groups will exchange ideas and preferences regarding use of tools as related to the scenarios analyzed. Faculty will end the session by providing a brief summary of concepts.

10 minutes Session Evaluation