Missed Opportunities for HPV Vaccination Discussion Among Medical Trainees

MISSED OPPORTUNITIES FOR HPV VACCINATION DISCUSSION AMONG MEDICAL TRAINEES Jahnavi Sunkara, BA Candidate; Emily J Noonan, Ph.D., M.A; Laura A. Weingartner, Ph.D., M.S.Abstract BACKGROUND Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States and can cause serious health problems like genital warts and cancer. However, vaccination can prevent some of these issues. Although the CDC recommends that individuals between 9-26 years old should receive the HPV vaccine, catch-up vaccination until 45 years old is available upon further guidance from healthcare providers. METHODS Standardized patient (SP) encounters (n=28) were randomly sampled from 134 video recordings of rising third-year medical student trainees. Students were prompted to take a patient history for a 32-year-old seeking to establish primary care who had not seen a physician in over a decade. The content of discussions regarding general and HPV vaccinations were coded for recommendation(s), rationale, and who prompted the discussion. RESULTS Medical trainees prompted the general vaccination discussion only 32% of the time and the HPV vaccine was discussed in only 22% of encounters. Of the patients who were recommended to get an HPV vaccine (n=4), all were assigned female at birth. The most commonly cited reason for not providing a vaccine recommendation was no vaccination records (71%). DISCUSSION These data illustrated gaps in HPV and general vaccination discussion among medical trainees, including missed opportunities to discuss HPV vaccination with patients who are assigned male at birth or who have not received care since before the vaccine’s debut. These trends may be reflected in primary care settings, and we thus recommend that routine vaccination history/discussion include the HPV vaccine for new patients establishing care

Eliciting Information During a Standardized Patient History

ELICITING INFORMATION DURING A STANDARDIZED PATIENT HISTORY AUTHORS Sydney Greene, BA Candidate; Emily J Noonan, PhD, MA; Laura A. Weingartner, PhD, MS BACKGROUND Learning how to take a detailed patient history is a fundamental skill that is essential for all medical students to master. Understanding the amount of information elicited in various categories of a patient history may reveal areas where many students struggle to engage the patient, gaps in medical education that could be addressed, or possible predictors of patient satisfaction. METHODS I coded videos of rising third year medical students as they took a patient history and counted each time the student elicited information, the student gave explanations, and the patient asked questions. These counts were compared across the main categories of the patient history, which included past medical history, a hormone use discussion specific to this encounter, family medical history, social history, mental health history, sexual history, and the treatment plan. RESULTS On average, students prompted for information 50 times during a new patient encounter while providing about 12 explanations. Under 4% of questions were related to the patient’s mental health on average compared to 23% of student questions about past medical history and 24% about social history. Patients asked about four questions on average, with most being asked during discussions of the treatment plan. DISCUSSION The results may indicate that students feel uncomfortable asking questions relating to mental health or that students feel mental health is less important to consider than other factors when taking a patient history. In comparison, students seem to feel confident and comfortable discussing the past medical history and social history of the patient. REFERENCES: Ha et al. Doctor-Patient Communication: A Review. Ochsner Journal. V(10):2010. Teutsch, Carol. Patient-Doctor Communication. Medical Clinics of North America. V(87):2003

HPV Vaccine Discussions Between Medical Students and Standardized Patients

The vaccination against human papillomavirus (HPV) protectsindividuals from cancer by preventing HPV infection. This vaccination is recommended for people who are assigned male or female at birth. However, since these groups are often associated with different risks of HPV infection, there may be gaps in how effectively the vaccination is recommended to patients. We gathered data by viewing recordings of medical students taking histories from standardized patients. We recorded if and which vaccinations were discussed as the patients established primary care. We focused on discussions surrounding HPV vaccines and used discussions around influenza vaccines as a comparison. We recorded if and how each vaccine was recommended, suggested, or discouraged. We reviewed 83 patient encounters. Only61% of students explicitly discussed vaccinations.Within these discussions, students were more likely to recommend or suggest vaccinations against influenza (63%) than HPV (29%). Students discussed the HPV vaccine more frequently with patients who were assigned female (within 56% versus 21% of vaccine discussions) but were slightly more likely to recommend amongthe assigned male patients(80% vs 73%). Many students used ambivalent or suggestive language rather than clear recommendations that communicatedt he importance of vaccination. Targeting HPV vaccine discussions toward patientswho are assigned female at birth leaves a large portion of society at risk for infection and transmission of HPV. Misinformation around vaccinations has caused many people to distrust vaccines, so it is critical for physicians to develop communication skills to effectively discuss and explain vaccines to patients.https://ir.library.louisville.edu/uars/1062/thumbnail.jp

Comparing Medical Student Nonverbal Behavior With Cisgender And Transgender Standardized Patients

It is essential for medical students to effectively communicate with patients of all gender identities. Evaluating nonverbal behavior is one way to assess the quality of patient care – examining providers’ behaviors while working with cisgender and transgender patients can identify potential biases linked to patient identity. To evaluate nonverbal behavior, the authors analyzed video-recorded training sessions with medical students interviewing standardized patients who identified as cisgender or transgender women. All students identified as cisgender men or cisgender women. The authors rated ten nonverbal behaviors from 1-7 and noted whether these behaviors were perceived to detract from the encounter. Average scores for nonverbal behaviors were similar between students working with cisgender and transgender patients. Nodding frequency showed the largest difference between cisgender (m = 5.65) and transgender (m = 4.93) patients. When considering student gender identity, cisgender men had lower facial expressivity and smiling frequency scores on average but higher scores for unnecessary silence compared to cisgender women across encounters. Detracting behaviors that negatively impacted the patient encounters were most likely to be self-touching/unpurposive movements (41%) and unnecessary silences (26%). Among the students, cisgender men demonstrated detracting behaviors at a higher rate than cisgender women. The consistency in nonverbal behavior during encounters with cisgender and transgender patients is encouraging. It is possible that LGBTQ health training in medical education contributed to this outcome; however, differences in verbal communication could contribute more to health disparities for transgender patients. Additional practice with unpurposive movements and unnecessary silences could improve nonverbal communication skills

Frequency and Perceived Authenticity of Social Determinants of Health Discussion by Medical Trainees

Introduction Social determinants of health (SDOH)—the conditions in which people live, learn, and work—play a vital, but often neglected role in shaping a community’s health. SDOH influence risk factors for disease and access to healthcare, consequently promoting health inequities among different populations. Examining how providers discuss SDOH with patients can identify opportunities to better integrate social context into care. Methods We analyzed standardized patient (SP) encounters of rising UofL M3 trainees to 1) determine whether SDOH are integrated into healthcare conversations, and 2) investigate what constitutes an authentic conversation to identify how trainees can better express interest in a patient. SP encounters (n=41) were randomly sampled from 139 video recordings of new patient histories. Discussions concerning SDOH categories were coded for content, patient response, and the perceived authenticity of each interaction. Results The most frequently discussed SDOH was employment (80.49% of encounters) while financial security (0%), healthcare access (2.44%), and discrimination (2.44%) were among the least discussed. Trainees appeared more engaged and interested when they empathized with patients, provided reassurance, established personal connections, and displayed a logical/organized flow of thought. Discussion Clinical skills around SDOH could be improved if students were provided more practice incorporating patients’ answers about SDOH into the health management plan. SDOH discussions can be used to get to know the patient holistically and foster strong doctor-patient relationships, both of which are crucial communication/clinical skills assessed by licensing exams. Emphasis on SDOH in medical education can help students advance these skills.https://ir.library.louisville.edu/uars/1039/thumbnail.jp

How medical students screen for HIV with standardized patients establishing care.

How Medical Students Screen for HIV with Standardized Patients Establishing Care AUTHORS Christopher J. Brown, B.S., B.A. Candidate; Emily J Noonan, PhD, MA; Laura A. Weingartner, PhD, MS BACKGROUND Approximately 1.1 million people in the U.S. are living with HIV. The US Preventive Services Task Force (USPSTF) recommends HIV testing for everyone 15-65 years old at least once regardless of sexual activity, with more frequent testing for those considered at risk. METHODS Rising third-year medical students were recorded taking health histories from standardized patients. These recordings were coded for HIV screening, including: risk factors such as unprotected sex, intravenous drug usage, multiple partners, patient/partner HIV status; contextualization by student as to how screening questions related to HIV; and discussion tone (accusatory, informative, or non-judgmental). RESULTS Of the 71 sampled encounters, students identified whether the patient knew their STI status without mentioning HIV status, and 10 students explicitly identified whether the patient knew their HIV status. Similarly, 13 students discussed the STI status of the patient’s partner(s) without mentioning HIV, while only 4 students discussed the HIV status of the patient’s partner(s). In total, only 7 out of 71 students recommended HIV testing to their patient. When discussing patient status, most students (34) were non-judgmental, but one used an accusatory tone while eight were informative. DISCUSSION The results show a lack of explicit HIV discussions and testing recommendations to patients despite USPSTF recommendations that all patients be tested. This study highlights that even when STI status is discussed, many students do not specify HIV status, an important distinction when providing preventive care. Future studies should address how perceived patient risk for HIV and patient identity impact HIV testing recommendations

Gender Identity and Pronoun Usage in Standardized Patient Encounters

The standardized documentation clinicians use to record evaluations of a patient are called Subjective, Objective, Assessment, and Plan (SOAP) notes. Consistent pronoun documentation and usage in these notes is especially important for affirming transgender and gender non-conforming patients as this population experiences significant health disparities linked to medical mistrust. A sample of SOAP notes (n=286) was taken from standardized patient encounters at the University of Louisville School of Medicine in 2017 (n=137) and 2018 (n=149). There were five case iterations of the standardized patient based on gender identity. The notes were coded using the software Dedoose for the following themes: pronouns clearly established, consistent pronoun usage, no pronoun usage, and disregard for established pronouns. Pronouns were clearly established in only 27.27% of the notes (n=78/286). Non-cisgender patients were more likely to have pronouns that were clearly established (41% vs 5%). Consistent pronoun usage was most often observed among the notes of cisgender patients. Inconsistent pronoun usage and disregard for established pronouns was observed most often for genderqueer patients (16%, n=14). Complete absence of pronoun use occurred in the notes of trans women (7%, n=3), genderqueer patients (8%, n=7), and cisgender women (3%, n=2) patients. These notes demonstrate a lack of rigor in recording pronouns accurately and consistently for patients, which can be profoundly detrimental to non-cisgender patient care. These discrepancies can be remedied by including training about gender-affirming care and interacting with non-cisgender patients in the clinical skills curriculum

Screening for E-cigarette and Tobacco Use in Standardized Patient Encounters

E-cigarette usage has grown significantly in recent years, with over 5 million US middle and high school students reporting recent usage. The long-term health consequences of these devices are still being investigated, but it is known that e-cigarette aerosol could contain harmful substances including nicotine, heavy metals, and carcinogens. Therefore, it is important for physicians to ask patients about e-cigarette usage specifically, as this may contribute to future health problems. The goal of this study was to investigate if and how medical students screen for e-cigarette usage. Screening language was reviewed in standardized patient encounters, which are a type of assessment that medical students undergo in order to observe how they interact with simulated patients. Video-taped patient encounters were coded to examine the specific phrasing of questions related to tobacco usage, including initial and follow-up questions. The majority of students (97%) did not ask about e-cigarettes specifically. Most students (66%) simply asked, “Do you smoke?” Overall, the evidence shows that e-cigarette and vaping device usage is not being addressed specifically in these interactions. These results demonstrate a need for updated patient screening in regards to tobacco use. Because the majority of e-cigarette users report not knowing that the product contains nicotine, physicians must be made aware of their unknown effects on patient outcomes and the need to screen specifically about e-cigarette usage separately from smoking. Continuing medical education may also help address this gap since many cohorts of practicing physicians were training before the popularity of these types of devices.https://ir.library.louisville.edu/uars/1035/thumbnail.jp