Climate change affects patient health through an array of exposures, including increasing heatwaves, extreme weather events, poor air quality, and expanding vector-borne illnesses. Physicians are at the forefront of addressing the health consequences of these exposures with patients, and environmental sustainability has become a priority for health care organizations. Accordingly, climate change and health is becoming a critical area for graduate medical education (GME). As GME leaders design and drive education in residency and fellowship programs, understanding those leaders’ baseline knowledge on this topic and its alignment with their organizations’ priorities is an essential step in the development of climate and health education programs. A search of existing climate and health knowledge assessments revealed an array of tools, yet most had limited applicability for physicians. We systematically created a brief GME climate and health baseline assessment requiring less than 10 minutes of users’ time. The assessment was administered anonymously via an online survey tool to GME leaders at three sponsoring institutions across three states within our health care system. Responses from 115 of 155 individuals (74% response rate) yielded an average 62% correct (standard deviation = 16%) and a score range of 10% to 90%. This baseline assessment identifies GME leaders’ knowledge gaps about climate change and its impacts on health, the role of health care organizations in producing planet-warming pollution accelerating climate change, and the prioritization of these issues within our organization.

BACKGROUND Motivated by racial injustice and COVID-19 disparities, health care and medical education are accelerating efforts to address racism and eliminate health disparities. METHODS In consultation with a community partner, an interprofessional physician-led team prioritized and completed an 8-hour anti-racism training adapted for online delivery during a pandemic. RESULTS Sixty-four percent of enrollees (25/36) completed the survey, 98% rated the training as valuable, 92% would recommend it to a colleague, 88% reported it would improve their clinical care, and 68% thought their ability to create an inclusive environment increased. DISCUSSION Virtual anti-racism training is a valuable learning experience. Tools for adapting trainings on high-risk or emotionally charged topics to a virtual format are offered by participants and session leaders.

The opportunity to teach is often cited as an important reason physicians become involved in graduate medical education (GME). As of July 1, 2019, the Accreditation Council for Graduate Medical Education Common Program Requirements will require faculty members to pursue formal faculty development designed to enhance their skills, including those as teachers. Research has demonstrated that while expert teachers often appear to teach (or perform) without a lesson plan, it is not unplanned. Expert clinical teachers take cues from the patient, learners, setting, and time available to decide which educational path to pursue. It's an interactive process determined by the responses of the learners (audience)—adapting the content and strategies to best meet learners' needs—a skillset that is commonly associated with improv.Improv is increasingly used in medical education as an approach to improve communication skills. But it has had limited application as a faculty development strategy focused on clinical teaching. Applied Improv, like clinical teaching, has key principles and rules ranging from “Be present” and “Respect your Partner” to “Yes and . . ..” When these skills are applied to a “teaching scene,” they yield faculty development exercises that are quick, practical, timely, and consistent with key principles of well-being (purpose and meaning as teacher, competence, relationship, autonomy). Our sessions begin, just as in improv, with at least one warm-up exercise. For example, participants shout out responses to an exercise called “Go with the possibility that clinical teaching is like improv because . . ..” This exercise requires participants to warm up cognitively by identifying commonalities. The “Teacher's Pet Peeves” dyad warm-up exercise starts with one participant stating a teaching “peeve” (Residents just don't read anything in depth—only what's on their app). The listener then has 60 seconds to reframe the peeve into a positive by connecting the emotion to a value (Clearly it is important to you that residents understand the “why” along with the “what” we do as physicians). These exercises require the teacher to be present, cognitively agile, and connect emotionally, thereby strengthening interpersonal connections and relationships. Various teaching scenes are then established by asking the audience to define “who,” “what,” and “where” questions, or scenarios can be provided. This gives participants the opportunity to apply the improv skills of “Agree,” “Yes and . . .,” and “Make Statements” (not questions disguised as statements, thereby showing respect and adding value to the interaction) as clinical teachers. Depending on time at the initial session, the teaching scenes can start (or continue to occur) at subsequent sessions. All sessions close with a large group debriefing discussion to identify benefits and barriers of using improv skills as teachers.This interactive and LOL (laugh-out-loud) approach to faculty development has been presented locally and nationally to rave reviews. Evaluations from a regional and a national meeting (N = 50) utilized a 4-point scale (1, strongly agree/yes definitely, to 4, strongly disagree/no definitely not) with mean responses for all items less than 1.2. The items included: The session “increased my repertoire of teaching strategies”; The session made me “be truly present—attentively listen, focused on now—not what I'm going to say next”; The session made me recognize that “improv utilizes many of the same skills associated with expert teaching” and I would “recommend this session to other medical educators.” The item “Session rocked/was a mic drop!” was rated strongly agree by over 85% of respondents (remainder agree). Long-term follow-up using local participants' teaching evaluations baseline/post is anticipated.

PURPOSE:Longitudinal education initiatives designed to prepare residents to address health disparities and social determinants of health (SDH) are needed. This report addresses this gap by describing a family medicine residency's Community Health, Advocacy, and Managing Populations (CHAMP) curriculum and its evaluation by learners, faculty, and community partners. The CHAMP longitudinal curriculum is explicitly designed to prepare residents to address health disparities and SDH. We report early outcomes, including community partner feedback, of this innovative curriculum. METHODS:Data were obtained through standardized rotation evaluations, thematic analysis of structured group and individual interviews, and aggregated competency milestone data. Kirkpatrick's four-level model to evaluate effectiveness of training was used to frame design and analysis of learner, faculty, and community partner evaluations. RESULTS:Twenty residents have completed the year-one curriculum, 8 residents the year-two curriculum, and 8 residents the year-two and year-three elective. Community partners, residents, faculty, and leadership all were satisfied with the curriculum, particularly regarding relationship building and mentorship. Overall satisfaction with the rotation, quantitatively and qualitatively, was positive. Competency milestone ratings improved within each year of training: first-year residents by 0.6 (3.0 for 2015-2016 and 3.6 for 2016-2017) and second-year residents by 0.1 (5.2 vs 5.3). CONCLUSIONS:The CHAMP curriculum uniquely a) spans all three years of residency; b) combines block mandatory rotations with a longitudinal elective experience; and c) integrates community health, advocacy, and managing populations to meet accreditation requirements and prepare residents to address health disparities and SDH.

Falls are an important geriatric syndrome with serious outcomes. Use of benzodiazepines, non-benzodiazepine hypnotics, and diphenhydramine increases the risk for falls and is modifiable. An interprofessional team created a falls and medication related Maintenance of Certification (MOC) Part IV activity for primary care physicians (PCPs) to meet American Board of Medical Specialists requirements. The activity prepares PCPs to initiate brief (2–3 min) conversations to reduce medication use by discussing its relationship to falls with geriatric patients. The MOC was launched as a workshop at a statewide PCP meeting using interactive educational strategies (quiz, patient educational tools, role play). A retrospective “post-post” evaluation assessed workshop processes and outcomes. 100% of attendees (14/14) completed the workshop evaluation. Analysis found very positive responses: 1) perceived decrease for 4 literature-based barriers to medication discussions; 2) increased likelihood to initiate conversations with patients about medications and falls; and 3) all were likely to recommend the session to a colleague. Participants targeted improvement aims between a 20%-50% increase in medication use conversations in their practices. Participants emphasized workshop’s foci on developing and testing scripts for conversations and utilization of proven patient education materials were key elements in likelihood to have conversations. PCPs initially perceived medication and falls discussions as fraught with barriers. A brief (90 min) interactive MOC activity reduced perceived barriers and increased PCP commitment to conduct medication and falls discussions with geriatric patients.

Background: Between 22% and 60% of practicing physicians are reported to have experienced burnout. OB/GYN resident burnout has been reported at 90%. Duty-hour limitations were implemented for patient safety and have been associated with some increase in overall resident quality of life, but also potential sacrifices in resident education and patient care. Contributors to burnout and drivers of engagement include workload and job demands, control and flexibility, and poor work-life integration.

Background: Colorectal cancer (CRC) is a national healthcare priority, as well as an Aurora Health Care (AHC) quality metric and a care gap per AHC’s CHNA. Our residency clinics face challenges associated with urban underserved populations, and the clinics are currently under the goal for the CRC screening quality metric. Studies have identified disparities in CRC screening, with screening less prevalent among patients who are uninsured and/or of lower socioeconomic status, African American/black, Asian, or non-English speaking Hispanic. Information on age-related disparities in CRC screening rates among eligible patients is limited. Methods: A team of residents/faculty framed our approach using the Institute for Healthcare Improvement Model for Improvement. Providers at 2 family medicine clinics identified barriers to CRC screening using a fishbone approach to engage them in the improvement process. A retrospective analysis of all patients eligible for CRC screening at 2 targeted clinics, a control clinic (a residency clinic in the same ZIP code), and our care region during a 12-month period (December-November 2015) was completed in collaboration with AHC quality improvement specialists. The percentage of patients achieving the CRC screening metric was reported by REAL-G (race, ethnicity, age, language, gender) and insurance status. Categories with an n 10%. The analysis was repeated in January 2017 for the intervention period (January-December 2016). Results: The analysis showed that screening rates at all facilities and in the care region overall were lowest among patients in the 50- to 54-year-old age bracket. Identifying a specific disparity group provided a focus for improvement. After the intervention, screening rates in this age group increased in the 2 targeted clinics and overall. Increased CRC screening rates appear to be influenced by improved CRC ordering workflows, clinic provider/staff education, and staff champions who are CRC advocates and who implement changes. The project created dialog about CRC screening rates in several AHC-wide groups, which may have encouraged change in our care region. Conclusion: Analyzing local population data via REAL-G categories provides new insights into how to reduce health disparity gaps and further our progress toward achieving best in our state care for all patients.

Background: Hospital readmission rates are a focus of the Centers for Medicare and Medicaid Services. This was identified as a system opportunity to improve health care quality and patient education in order to reduce preventable readmissions. In 2009, 27% of obstetric readmissions were due to hypertensive disease, and preventable readmissions regarding hypertension are flagged as an area for quality improvement in our health care system. There is limited evidence on specific management of postpartum hypertension. Purpose: Identify risk factors in our community and reduce postpartum readmissions for hypertension within our hospital. Methods: We performed a retrospective chart review from November 2014 to November 2015. We collected demographic data, comorbidities and information regarding hospitalization and readmission. In this, we identified 28 readmissions for postpartum hypertension, representing 57% of obstetric readmissions and noted that discharge instructions and blood pressure monitoring postpartum were two areas for improvement. Only 18% had printed instructions regarding postpartum hypertension. Via multidisciplinary education sessions, we aimed to increased surveillance for postpartum vitals for at-risk patients and provide appropriate verbal and written precautions for signs and symptoms of de novo or worsening hypertensive disease. We also improved access to care by scheduling blood pressure checks within 72 hours of discharge and utilization of visiting nursing services for blood pressure checks. The same measures were then recollected for readmissions from June 2016 to December 2016. Results: After intervention, 61% of readmissions were related to hypertension, with 31 readmissions. Overall, there was a significant improvement in written discharge instructions regarding postpartum hypertension, with 94% receiving written instructions. At discharge, 33% had blood pressure checks and 13% had visiting nursing services arranged. Conclusion: Postpartum hypertension is more recognized, and readmissions are becoming more common. We increased efforts to optimize medical management of hypertension and reduce preventable readmissions. Improvement in discharge instructions for patients did not decrease overall admission for postpartum hypertension but may have improved overall patient care. Overall cost analysis would be beneficial to see further economic impact.

Background: Health care systems continuously seek to improve patient care through population-level analysis of clinical quality metrics and patient characteristics to identify disparities in care. Nationally, disparities in colorectal cancer (CRC) screening rates have been identified with lower screening rates reported for patients who are uninsured and/or lower socioeconomic status, African American/black, Asian, and non-English-speaking Hispanic patients. No age-related CRC screening rate disparities with associated interventions have been reported. Purpose: Determine and address CRC screening disparities in care provided to eligible patients > 50 years old in two primary care residency clinics. Methods: Retrospective analysis using REAL-G (race, ethnicity, age, preferred language, gender) categories and insurance coverage was completed on a 12-month data set to identify presence of CRC screening disparities. Barriers to CRC screening for largest disparity gap were then identified by clinic staff at two family medicine residency clinics (a third primary care clinic in same zip code and service region were used for nonintervention comparison) using the Institute for Healthcare Improvement fishbone approach. The project team, informed by the literature, then identified and implemented targeted interventions, monitoring progress during a 6-month period. Interventions included provider education with periodic reminders regarding system-approved CRC screening options and a workflow-based intervention. Postintervention analysis was completed using same preintervention approach. Results: The largest CRC screening disparity for region and clinics was associated with age, with screening gaps ranging from 13% to 15% between populations aged 50–54 years versus > 65 years. CRC screening rate disparities by race, ethnicity, and gender were less than 10%. Postintervention, one targeted clinic had a 6% increase in the CRC screening rates in the target population (age: 50–54) while a second targeted clinic had a 1% increase in screening rates during this period. The comparison primary care residency clinic had a 1% decline in CRC screening rates. Differences in insurance utilization types for CRC screening rates by clinic were noted. Differences between targeted clinic screening rates were attributed to successful workflow implementation and provider/staff champions. Conclusion: Analyzing population data at a micro/clinic level using REAL-G categories can inform targeted interventions that aim to reduce health disparity gaps.

Background: Physicians and patients agree that primary care visits are the appropriate place to discuss advance directives (AD) with geriatric patients as it normalizes the discussion. Yet barriers are known to keep AD completion rates low. Methods: An interprofessional team designed and implemented a three-health care system approved AD focused Maintenance of Certification (MOC) Part IV activity for primary care physicians (PCPs) to meet American Board of Medical Specialists (ABMS) requirements. The activity focuses on PCPs initiation of brief (2–3 min) AD conversations with geriatric patients. The activity was launched at a statewide PCP meeting using a workshop that employed interactive educational strategies (quiz, video analysis, role play). Retrospective “post-post” evaluation focused on workshop processes and outcomes. Results: Eight PCPs completed the session reporting that at baseline the modal number of conversations PCPs initiated each week about ADs was < 1/week (range 0 to > 10). All participants targeted a minimum 25% increase in AD conversations as the improvement goal. Post workshop evaluation analysis found: 1) improvement among four literature-based barriers to AD discussions in the aggregate of responses; 2) all participants were more likely to initiate conversations with patients about ADs; and 3) 88% (7/8) were “very likely” to recommend the session to a colleague. Conclusion: Experienced PCPs perceive AD discussions as fraught with barriers. This brief (90 min) interactive AD discussion focused MOC activity minimized perceived barriers and increased primary care physician commitment to increase AD discussions with geriatric patients.