Office Of Academic Affiliations Research Articles

Development of Health Professions Education Competencies for a National Fellowship Program: A Group Consensus Process.

Health professions educators need knowledge, skills, and attitudes to provide high-quality education within dynamic clinical learning environments. Although postgraduate training opportunities in health professions education (HPE) have increased significantly, no shared competencies exist across the field. This article describes the systematic development of postgraduate HPE competencies for the Health Professions Education, Evaluation, and Research (HPEER) Advanced Fellowship, a 2-year, interprofessional, post-master's degree and postdoctoral HPE training program funded through the Department of Veterans Affairs' Office of Academic Affiliations. Using a modified RAND/University of California at Los Angeles Appropriateness Method, the authors developed competencies from March 2021 to August 2021 that were informed by current practices and standards in HPE. Literature reviews were conducted of published literature from November 2020 to February 2021 and gray literature from February to March 2021, identifying 78 and 274 HPE training competencies, respectively. These competencies were combined with 71 competencies submitted by program faculty from 6 HPEER fellowship sites, resulting in 423 initial competencies. Competencies were organized into 6 primary domains and condensed by deleting redundant items and combining overlapping concepts. Eight subject matter experts completed 3 Delphi surveys and met during 2 nominal group technique meetings. The final 25 competencies spanned 6 domains: teaching methods and learning theories; educational assessment and program evaluation; educational research methods; diversity, equity, and inclusion; interprofessional practice and team science; and leadership and management. In addition to informing the national HPEER curriculum, program evaluation, and learner assessment, these advanced competencies describe the knowledge, skills, and attitudes health professions educators need to provide high-quality education with an emphasis on the global and societal impact of HPE. These competencies represent a step toward leveraging HPE expertise to establish competencies to drive HPE program changes. Other programs should report their competencies and competency development processes to spur further dialog and progress.

Justification for initiating patiromer when restricted by prior authorization and clinical guidance in a US health care system.

BACKGROUND: In the Veterans Health Administration, patiromer is a formulary medication restricted by prior authorization and criteria-for-use (CFU). Historically, patiromer approval was restricted by step therapy, requiring prescribers to trial sodium polystyrene sulfonate (SPS). OBJECTIVE: To describe clinical scenarios leading to patiromer initiation by characterizing patient experience with primary hyperkalemia treatment modalities, especially SPS. METHODS: All veterans who initiated patiromer between January 1, 2016, and February 28, 2021, with chronic kidney disease and dispensed SPS during the 3 months preceding patiromer were included. A structured chart-review process was used to abstract prior authorization drug request notes to characterize patiromer approval and patient experience with primary pharmacotherapy. Results were reported with descriptive frequencies and proportions. RESULTS: Three hundred thirty-one veterans met inclusion criteria. Primary justification for patiromer initiation included continuation of patiromer initiated outside the Veterans Health Administration or during inpatient stay (5.7%) and SPS inventory shortage (25.4%). CFU justification was mentioned in 83.7% of notes and, among those with CFU justification, SPS treatment was documented in 68.7%. Clinician statements indicating that SPS was ineffective occurred in 65 (41.7%) and statements of safety concerns (either observed or potential) in 37 (23.7%) veterans. CONCLUSIONS: Patiromer approval is multifactorial, and clinicians often opted to avoid long-term SPS use because of safety concerns, lack of consistent availability, and concerns about its appropriateness for longterm hyperkalemia management. DISCLOSURES: Drs Patel and Sauer received funding from Otsuka Canada Pharmaceutical Inc. to study the use of patiromer in the VHA. This material is the result of work supported with resources and the use of facilities at the VA Salt Lake City Health Care System. The views expressed in this manuscript are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the US government. Drs Qualls and Pinnell are supported by the VA Advanced Fellowship Program in Medical Informatics with the Office of Academic Affiliations. This work was funded through a partnered research mechanism. Otsuka Canada Pharmaceutical Inc. was not involved in development or review of this manuscript.

How the VA is training the Next-Generation workforce for learning health systems.

ObjectivesThe U.S. Department of Veterans Affairs (VA) has been a national leader in Learning Health System (LHS) implementation due to its combined mission of research, education, clinical care, and emergency preparedness. We describe the current VA LHS training ecosystem within the Veterans Health Administration's Office of Academic Affiliations (OAA), Office of Research and Development (ORD), ORD's Health Services Research and Development (HSR&D) program, and Innovation Ecosystem (IE), including lessons learned regarding their sustainment.MethodsThe VA LHS training ecosystem is based on the Learning Loop and HSR&D Quality Enhancement Research Initiative (QUERI) Roadmap, which describes VA learning opportunities, underlying infrastructures, and core competencies.ResultsVA‐focused LHS educational programs include data‐to‐knowledge initiatives in health sciences and analytics, for example, OAA/HSR&D health services and informatics research fellowships; knowledge‐to‐performance opportunities in implementation and quality improvement, for example, QUERI Learning Hubs and IEs' Diffusion of Excellence Initiative; and performance‐to‐data embedded opportunities, for example, IE's entrepreneur fellowship programs and QUERI's Advancing Diversity in Implementation Leadership. These training programs are supported by combined VA research and clinical operations investments in funding, informatics, governance, and processes. Lessons learned include ongoing alignment of research funding with operational priorities and capacity, relentless recruitment and retention of implementation, system, and information scientists especially from under‐represented groups, sustainment of data infrastructures suitable for research and quality improvement, and ensuring sustainable funding opportunities for researchers to work on system‐wide health care problems.ConclusionsThere is an urgent need to expand training opportunities in LHSs, especially as health care is increasingly driven by multiple interested parties, impacted by persistent health disparities exacerbated by emerging public health threats, and rapid technology growth. With ongoing alignment of research and clinical goals, foundational support through research funding, underlying clinical operations infrastructures, and active engagement interested parties, VA's LHS training ecosystem promotes a more LHS‐savvy, 21st century workforce.

1628. Treatment Heterogeneity in Pseudomonas aeruginosa Pneumonia

BackgroundSerious bacterial infections present a unique challenge for studies of real-world evidence. Often, the causative organism is unknown during the initial period of treatment and clinical symptoms change day-to-day, which lead to multiple changes in therapy. While it is assumed approaches to treating specific infectious diseases are mostly similar, we’ve previously identified substantial treatment heterogeneity, even among organism-specific and site-specific infections.MethodsOur retrospective cohort study included inpatients with positive P. aeruginosa from sputum and bronchoalveolar lavage cultures collected during VA medical center and community living center stays from 01/15-04/18. We included the first positive culture during the admission per patient. Daily antibiotic exposures were mapped from 3 days prior to the culture collection date until discharge or 30 days for longer stays. Heterogeneity was defined as patterns of antibiotic treatment (drug and duration) not shared by any other patient.ResultsOur study included 5,435 patients and 87.4% of patients had different patterns of antibiotic drug and duration. Among patients with changes in therapy (84.0%), 96.9% had different antibiotic treatment patterns, with a median time to first change of 1 day and median of 3 changes. When restricting the analysis to antibiotic classes (rather than drug), Gram-negative antibiotics, and anti-pseudomonal antibiotic classes, heterogeneity was 81.8%, 52.0%, and 48.7%, with median time to first change of 1, 3, and 3 days, and a median of 3, 2, and 2 changes, respectively.ConclusionAmong inpatients with positive P. aeruginosa respiratory cultures, substantial heterogeneity was observed in the national VA Healthcare System. Even at the class level, and restricting the analysis to anti-pseudomonal antibiotic classes, approximately 50% of patients had different treatment patterns during their inpatient stay. Current methods to assess treatment do not adequately account for the extensive heterogeneity observed in infectious diseases and it remains unclear how local or national treatment guidelines affect heterogeneity.Disclosures Aisling Caffrey, PhD, Merck (Research Grant or Support)Pfizer (Research Grant or Support)Shionogi (Research Grant or Support) Emily C. Bodo, Pham.D, VA Office of Academic Affiliations (OAA) (Other Financial or Material Support, Bodo is supported by the VA Office of Academic Affiliations (OAA)) Laura A. Puzniak, PhD, Merck (Employee) Kerry LaPlante, PharmD, Merck (Advisor or Review Panel member, Research Grant or Support)Ocean Spray Cranberries, Inc. (Research Grant or Support)Pfizer Pharmaceuticals (Research Grant or Support)Shionogi, Inc. (Research Grant or Support)

Expanding Workforce Capacity to Care for Older Veterans: The VA GRECC Interprofessional Training Experience

The Veterans Health Administration (VHA) contributes more to training healthcare professionals in geriatrics/gerontology than any other entity nationally, with the Geriatric Research Education and Clinical Center (GRECC) network serving as a leader in geriatric-/gerontology-specific interprofessional education. The Associated Health Training (AHT) Program is supported by all GRECCs, training ~427 trainees annually (FY17). Each AHT program brings together a diverse array of trainees – the specific constellation of disciplines unique to each GRECC based on local capacity/expertise. Common to all programs is intentional interprofessional training, aligned with Interprofessional Education Collaborative (IPEC) competencies. In 2016, the VA Office of Academic Affiliations (OAA) administered a 22-item survey to characterize the depth and breadth of geriatric-/gerontologic-specific interprofessional education across GRECCs. Questions explored how AHT programs addressed each of the four IPEC competency domains. Responses were de-identified; at least 2 coders independently applied directed coding to responses. Across GRECCs (n=18), 323 interprofessional training activities were coded, of which 9% were didactic; 27%, clinical; and, 63%, combination. Interprofessional education activities were integrated with profession-specific curricula (65.3%) or featured as part of GRECC-specific core curricula (5.4%). GRECC AHT interprofessional programs involved an average of 11 disciplines. GRECC AHT programs provide a vital infrastructure for building workforce capacity through robust, interprofessional training that engages diverse disciplines across a variety of care settings representing the continuum of care for older Veterans. GRECC and OAA efforts are critical to enhancing the quality, and expanding the capacity, of this workforce to meet increasing needs for patient-directed, team-based care for older adults.

0083 Slow Wave Activity During Sleep is Associated with Longitudinal Change in Overnight Memory Recall

Abstract Introduction Duration of slow wave sleep (SWS) declines with age and may not be the most sensitive biomarker for memory in older adults. Analyzing the spectral power of slow wave activity (SWA) (0.5–4 Hz) may provide a more sensitive measure to capture the impact of sleep on memory. We investigated the association of SWA at baseline with the change of overnight memory recall over one year in older adults. Methods Participants were 42 community-dwelling healthy older adults (22 women and 20 men). We performed a polysomnography (PSG) and list-learning memory tests at baseline (T1) and after a one-year follow-up (T2). The procedure includes, 1) the participants memorized a 16 word list in the evening, 2) after a 5 minute delay, participants wrote down as many words as they could remember (evening recall), 3) overnight PSG was then performed, and 4) the following morning, participants wrote down as many words from the original list from the night before (overnight memory recall). This procedure was repeated at T2. Mixed modeling was utilized to analyze the association between baseline SWA and trajectory of overnight memory recall. Results For the SWA component, higher relative power of slow oscillation (0.5–1 Hz) during the first ultradian cycle at baseline was correlated with a greater decline in overnight memory recall after 1 year (t = -2.198, p = .034), which covaried for age and gender. There was no correlation with evening recall. Relative power of delta (1–4 Hz) range activity did not show an association with evening and overnight memory recall. Conclusion Higher relative power of slow oscillation at baseline predicts a greater decline of overnight memory recall. This may indicate a differential effect among the frequency ranges of SWA on longitudinal change in memory in older adults. Support This work was supported by National Institute of Health grants MH 070886, AG 18784 and AG17824 and the Office of Academic Affiliations, Advanced Fellowship Program in Mental Illness Research and Treatment, Department of Veterans Affairs.

0467 Benefits of CBT-I for Women Veterans with and without PTSD

Abstract Introduction A quarter of women Veterans (WVs) receiving VA healthcare meet diagnostic criteria for both insomnia disorder and posttraumatic stress disorder (PTSD). Cognitive Behavioral Therapy for Insomnia (CBT-I) is effective at improving sleep among individuals with comorbid psychiatric conditions; however, no studies have examined the impact of CBT-I in women with insomnia plus PTSD. The current analyses examined changes in sleep symptoms, quality of life (QoL), and mental health symptoms from pre- to post-CBT-I in WVs with and without PTSD. Methods This was a secondary analysis of 75 WVs with insomnia (32 with probable PTSD), who received CBT-I within a behavioral sleep intervention study (NCT02076165). Measures completed at baseline, posttreatment, and 3-month follow-up included: insomnia severity (Insomnia Severity Index, ISI), sleep quality (Pittsburgh Sleep Quality Index, PSQI), PTSD symptoms (PTSD Checklist-5, PCL-5; probable PTSD=total score ≥33), depressive symptoms (Patient Health Qestionnaire-9, PHQ-9), and mental and physical quality of life (Short Form Health Survey, SF-12). One sample T-tests examined changes in ISI, PSQI, PHQ-9, PCL-5, and SF-12 from baseline to posttreatment and baseline to follow-up. Two samples T-tests compared change scores in ISI, PSQI, PHQ-9, and SF-12 between participants with and without PTSD. Results There were significant improvements in ISI (p≤.001), PSQI (p≤.001), PHQ-9 (p≤.001), PCL-5 (p=.001), and SF-12 mental (p≤.001) and physical (p=.03) from baseline to posttreatment and 3-month follow-up (p≤.001-.01). There were no significant change score differences between WVs with and without PTSD from baseline to posttreatment (p=.06-.98) or 3-month follow-up (p=.09-.93). Conclusion CBT-I appears to be an effective treatment to improve insomnia symptoms among WVs with and without PTSD, and may reduce psychiatric symptoms as well. These findings suggest WVs with comorbid insomnia and PTSD benefit from CBT-I. The appropriate sequencing of CBT-I and PTSD treatments remains potentially important, but unstudied. Support VA/HSR&D IIR-HX002300; NIH/NHLBI K24HL14305; VA Office of Academic Affiliations through the Advanced Fellowship Programs in HSR&D and Women’s Health

0131 Decreased Habitual Sleep Efficiency is Associated with Increased Insulin Resistance in Healthy Adult Men

Abstract Introduction Partial sleep deprivation is associated with increased insulin resistance (IR), a metabolic disease risk marker. Little is known about habitual sleep patterns and IR in the absence of acute sleep restriction. We anticipated greater change in habitual sleep over one month would be associated with increased IR. Methods 24 males (age=33.6±6.4 years; BMI=25.7±2.5kg/m2) completed baseline (T1) and follow-up (T2; ≥4 weeks post-T1) study procedures: actigraphy (one week) followed by polysomnography (PSG; one 10h sleep opportunity) and a next morning oral glucose tolerance test (OGTT; homeostatic model assessment insulin resistance [HOMA-IR], β-cell function [HOMA-β], and Matsuda Index). Weekly average actigraphy total sleep time (aTST; 291-511min) and sleep efficiency (aSE; 72–93%) were computed at T1 and T2, as well as across the 1, 2, and 3 days prior to PSG/OGTT. Pearson and Spearman correlations assessed the change (T1-T2) in actigraphy (aSEΔ, aTSTΔ, PSGΔ) or PSG sleep (PSG-TSTΔ, PSG-SEΔ, sleep stages) versus change in metabolic risk (HOMA-IRΔ, HOMA-βΔ, MatsudaΔ). Results There were significant correlations between HOMA-IRΔ and aSEΔ [r(22)=-0.42, p=0.01; rs=-0.45, p=0.03], PSG TSTΔ [r(22)=0.50, p=0.012; rs=0.41, p=.045], and PSG-SEΔ [r(22)=0.49, p=0.015; rs=0.43, p=.037]. No significant associations emerged between change in metabolic risk versus aTSTΔ one week prior to PSG/OGTT, aSEΔ or aTSTΔ across 1–3 days prior to PSG/OGTT, or PSG sleep stages. Conclusion Within-subject T1-T2 decrease in habitual sleep quality, but not TST, was associated with increased IR. T1-T2 PSG TST and SE were associated with following day IR. At home sleep 1–3 days beforehand were not correlated with IR. Although preceding night sleep quality and TST are associated with IR, habitual sleep quality, rather than TST, may be a more important determinant of metabolic risk in community dwelling middle-aged men. Support This work was supported by NIH/NHLBI R01HL124211, NIH/NHLBI K24HL138632, NIH National Center for Advancing Translational Sciences (NCATS) UCLA CTSI Grant UL1TR001881 (PI: Liu); and NIH/NHLBI K24HL143055 (PI: Martin). Dr. Kelly is supported by the VA Office of Academic Affiliations through the Advanced Fellowship Programs in Geriatrics.

Patient, Family, and Community Advisory Councils in Health Care and Research: a Systematic Review.

Patient-centeredness is a characteristic of high-quality medical care and requires engaging community members in health systems' decision-making. One key patient engagement strategy is patient, family, and community advisory boards/councils (PFACs), yet the evidence to guide PFACs is lacking. Systematic reviews on patient engagement may benefit from patient input, but feasibility is unclear. A team of physicians, researchers, and a PFAC member conducted a systematic review to examine the impact of PFACs on health systems and describe optimal strategies for PFAC conduct. We searched MEDLINE, Embase, PsycINFO, CINAHL, Scopus, and Social Science Citation Index from inception through September 2016, as well as pre-identified websites. Two reviewers independently screened and abstracted data from studies, then assessed randomized studies for risk of bias and observational studies for quality using standardized measures. We performed a realist synthesis-which asks what works, for whom, under what circumstances-of abstracted data via 12 monthly meetings between investigators and two feedback sessions with a hospital-based PFAC. Eighteen articles describing 16 studies met study criteria. Randomized studies demonstrated moderate to high risk of bias and observational studies demonstrated poor to fair quality. Studies engaged patients at multiple levels of the health care system and suggested that in-person deliberation with health system leadership was most effective. Studies involving patient engagement in research focused on increasing study participation. PFAC recruitment was by nomination (n = 11) or not described (n = 5). No common measure of patient, family, or community engagement was identified. Realist synthesis was enriched by feedback from PFAC members. PFACs engage communities through individual projects but evidence of their impact on outcomes is lacking. A paucity of randomized controlled trials or high-quality observational studies guide strategies for engagement through PFACs. Standardized measurement tools for engagement are needed. Strategies for PFAC recruitment should be investigated and reported. PFAC members can feasibly contribute to systematic reviews. A protocol for record eligibility was developed a priori and was registered in the PROSPERO database of systematic reviews (registration number CRD42016052817). The Department of Veterans Affairs' Office of Academic Affiliations, through the National Clinician Scholars Program, funded this study.

Interprofessional transformation of clinical education: The first six years of the Veterans Affairs Centers of Excellence in Primary Care Education

ABSTRACTThis paper describes the Centers of Excellence in Primary Care Education (CoEPCE), a seven-site collaborative project funded by the Office of Academic Affiliations (OAA) within the Veterans Health Administration of the United States Department of Veterans Affairs (VA). The CoEPCE was established to fulfill OAA’s vision of large-scale transformation of the clinical learning environment within VA primary care settings. This was accomplished by funding new Centers within VA facilities to develop models of interprofessional education (IPE) to teach health professions trainees to deliver high quality interprofessional team-based primary care to Veterans. Using reports and data collected and maintained by the National Coordinating Center over the first six years of the project, we describe program inputs, the multicomponent intervention, activities undertaken to develop the intervention, and short-term outcomes. The findings have implications for lessons learned that can be considered by others seeking large-scale transformation of education within the clinical workplace and the development of interprofessional clinical learning environments. Within the VA, the CoEPCE has laid the foundation for IPE and collaborative practice, but much work remains to disseminate this work throughout the national VA system.

A prism of excellence: The Charleston Veterans Administration Nursing Academic Partnership

BackgroundThe Veterans Administration (VA) has been committed to academic affiliate training partnerships for nearly 70 years in efforts to enhance veteran-centric health care. One such effort, the VA Nursing Academy (VANA) program, was developed in 2007 in response to the nationwide nursing shortage and began as a five-year pilot with funding competitively awarded to 15 partnerships between local VA medical centers and schools of nursing. The VANA program evolved into the VA Nursing Academic Partnership (VANAP) program following the initial pilot. PurposeThis article describes the development and evolution of the Charleston VANAP, which includes the Ralph H Johnson VA Medical Center (RHJ VAMC) and the Medical University of South Carolina College of Nursing (MUSC CON). MethodsThe VA Office of Academic Affiliations (OAA) funded a large portion of the initial five years of the Charleston VANAP. Once the national funding source ceased, the RHJ VAMC and the MUSC CON entered into a Memorandum of Understanding (MOU) to offer in-kind contributions to the partnership. DiscussionThe Charleston VANAP is the only program in the nation to offer three different nurse trainee programs and this article highlights some of the more notable achievements from each program. ConclusionThe Charleston VANAP is a comprehensive partnership between the RHJ VAMC and the MUSC CON that truly demonstrates a commitment to assure that the very best care be provided to Veterans, our Nation's heroes.

Transforming veterans health care through academic-practice partnerships

The Veterans Health Affairs Office of Academic Affiliations (OAA) has invested in the creation of academic-practice partnerships to transform the care of veterans and their families. This article details how a long-standing relationship between the University of Alabama at Birmingham School of Nursing and the Birmingham Veterans Affairs Medical Center grew into such a partnership. The three programs that now exist within the Birmingham Veterans Affairs Nursing Academic Partnership (VANAP) umbrella are described, including an undergraduate VA nurse scholars program that has sustained beyond OAA funding, a VANAP graduate education program for psychiatric mental health nurse practitioners (NPs), and a Mental Health NP Residency. Key features of the programs are noted as are outcomes and lessons learned for building mutual goals and a sustainable academic-practice partnership. With the recent passage of the Veterans Choice Program, the importance of educating all nurses about veterans and veterans' health is stressed.

The development of professional identity and the formation of teams in the Veterans Affairs Connecticut Healthcare System's Center of Excellence in Primary Care Education Program (CoEPCE).

The United States Department of Veterans Affairs Connecticut Healthcare System (VACHS) is one of five Centers of Excellence in Primary Care Education (CoEPCE) pilot sites. The overall goal of the CoEPCE program, which is funded by the Office of Academic Affiliations, is to develop and implement innovative approaches for training future health care providers in postgraduate education programs to function effectively in teams to provide exceptional patient care. This longitudinal study employs theoretically grounded qualitative methods to understand the effect of a combined nursing and medical training model on professional identity and team development at the VACHS CoEPCE site. The authors used qualitative approaches to understand trainees' experiences, expectations, and impressions of the program. From September 2011 to August 2012, they conducted 28 interviews of 18 trainees (internal medicine [IM] residents and nurse practitioners [NPs]) and subjected data to three stages of open, iterative coding. Major themes illuminate both the evolution of individual professional identity within both types of trainees and the dynamic process of group identity development. Results suggest that initially IM residents struggled to understand NPs' roles and responsibilities, whereas NP trainees doubted their ability to work alongside physicians. At the end of one academic year, these uncertainties disappeared, and what was originally artificial had transformed into an organic interprofessional team of health providers who shared a strong sense of understanding and trust. This study provides early evidence of successful interprofessional collaboration among NPs and IM residents in a primary care training program.

An interprofessional clinical advanced fellowship in rehabilitation serving Veterans with polytrauma and brain injury

Traumatic brain injury is a public health issue worldwide; about 1.7 million new incidents occur annually in the United States. This paper describes an innovative advanced educational fellowship in interprofessional polytrauma/traumatic brain injury rehabilitation sponsored by VA's Office of Academic Affiliations. Development and implementation of the James A. Haley Veterans' Hospital' Interprofessional Polytrauma/Traumatic Brain Injury (IP/TBI) Rehabilitation Clinical Advanced Fellowship in Optometry is described. This unique interprofessional educational experience is designed to enhance clinical skills of optometrists caring for Veterans with TBI and other acquired neurological disorders. Assessment and rehabilitation of visual dysfunction as part of the interprofessional rehabilitation approach are discussed. The IP/TBI Rehabilitation Clinical Advanced Fellowship provides a unique opportunity for select optometrist fellows to develop advanced skills as essential interprofessional team members providing TBI visual rehabilitative care for our Nation's Service Members and Veterans.

Advancing Post-Doctorate of Nursing Practice Residency Experience: First Year Reflections

An interprofessional team developed a yearlong post-doctorate of nursing practice (DNP) residency program funded by the Veteran Affairs (VA) Office of Academic Affiliations. As the VA’s first post-DNP residency, this multidisciplinary team sought to develop a mentoring environment that would provide DNP residents with increased clinical training, interprofessional networking, role transition, and dedicated mentoring. The authors discuss critical design elements for a successful residency design along with lessons learned. Initial findings support continuation and solidification of post-DNP residencies for new DNPs.

“Surely, We Can Do Better”

To the Editor: A paradigm shift is under way in medical education—or so the myriad responses to Academic Medicine’s 2011 Question of the Year1 suggest. The central argument made by the authors of those responses: The academy must broaden the societal reach of academic medicine to prepare trainees for today’s health care system. To paraphrase Porter and Teisberg2: Surely, we can do better. The challenge is determining how to achieve their collective aim. How do we move from the white paper to the white coat? We believe there needs to be real-time integration of the authors’ varied solutions into a cohesive whole, one that emphasizes translational action. And we need evidence to prove that this transformation is both attainable and desirable. To achieve these goals, we offer a potential model: the VA Connecticut Center of Excellence (COE) in Primary Care Education, established in 2011 by the Veterans’ Health Administration (VHA) Office of Academic Affiliations as one of five national centers focused on interprofessional medical education. We maintain that the principles within this model, stated below, offer potential answers to the challenge before us. First, the foundation of efforts to broaden the societal reach of academic medicine must rely on interprofessional collaboration—a rich and essential component of modern U.S. health care. Second, the curricula for this effort, taught in medical schools, must emphasize the unique skill set that enhances such collaboration, with frontier concepts in public leadership, health policy and economics, negotiation, conflict resolution, improvement science, and political advocacy key to that effort. Third, the education must be immersive, with the longitudinal exposure to meaningful clinical and didactic experiences necessary to equip trainees with skills to generate broad social impact. Team-based delivery models—such as the COE’s clinical practice in the VHA’s Patient Aligned Care Teams, supported by the integrated electronic medical records and global payment systems inherent to the integrated delivery system—may add value. Fourth, modalities linked to improved clinical outcomes, including shared decision making and sustained application of performance and systems improvement strategies, must be integral components of such efforts. Finally, these models must serve as “exemplary care and learning sites,” intended for replication with the potential for rapid, dramatic scaling upward. Achieving the paradigm shift we seek in medical education demands evidence-driven, patient-centered results. Restructuring of traditional medical and nursing education models away from a “siloed” approach toward collaborative learning experiences—within meaningful educational homes—may be the first step. This shift must also include integration of improvement science into all actions and deliberate skill development in policy, management, leadership, and public service. Critics may suggest that it is impossible to integrate these disparate elements into medical education. Our initial experience with the COE model argues otherwise. The societal challenges of our time demand action. Educational models that transform interprofessional education while simultaneously preparing trainees to meet those challenges may be the solution. Disclaimer: The views expressed in this letter are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. Ali M. Khan, MD, MPP Resident director, VA Connecticut Center of Excellence in Primary Care Education, West Haven, Connecticut, and clinical resident in medicine, Yale School of Medicine, New Haven, Connecticut; [email protected] Theodore Long, MD Resident director, VA Connecticut Center of Excellence in Primary Care Education, West Haven, Connecticut, and clinical resident in medicine, Yale School of Medicine, New Haven, Connecticut. Rebecca Brienza, MD, MPH Codirector, VA Connecticut Center of Excellence in Primary Care Education, West Haven, Connecticut, and assistant professor, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut.

Factors Associated with the Satisfaction of Millennial Generation Dental Residents

Data from the 2010 Learners' Perceptions Survey (LPS) administered through the Office of Academic Affiliations, Department of Veterans Affairs (VA) were analyzed to identify factors associated with dental residents' satisfaction with the VA as a clinical training environment. Satisfaction scores were linked to clinic workloads, dental procedure complexity levels, staffing patterns, and facility infrastructure data to explore conditions that may improve residents' satisfaction. Findings supported the construct validity of the LPS survey data and underscored the importance of maintaining optimal ratios of attending dentists, dental assistants, and administrative staff to residents so that each trainee will have opportunities to perform an adequate level of dental workload. As programs strive to improve the quality of graduate dental education, findings from this study are vital for setting curriculum design guidelines and for providing infrastructure support for dental resident education.

How Good Are Observational Studies in Assessing Psychiatric Treatment Outcomes?

How Good Are Observational Studies in Assessing Psychiatric Treatment Outcomes?

Best Practices: Environmental and Therapeutic Issues in Psychiatric Hospital Design: Toward Best Practices

The psychiatric hospital environment plays a significant, though often underappreciated, role in patient and staff functioning. This column reviews the literature on important environmental and therapeutic issues in psychiatric hospital design. Research findings and clinical conjecture reported over the past 50 years indicate that intervening environmentally through clinically informed, patient-centered design can improve functioning both among and between patients and staff. This column identifies specific best practice considerations and recommendations for designing inpatient psychiatric facilities and may serve as a useful planning resource to those interested in adopting a patient-centered, inclusive approach to design and treatment.