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October 3, 2018

Interview with Dr. Randi Sokol from Tufts University

Type: News Tags: Interview, Evidence Based Curricula, Residency, Primary Care

This month the NCIBH spoke to Tufts University's director of faculty development and pain/addictions curriculum, Dr. Randi Sokol.

Tufts University Family Medicine Residency Program is a university affiliated community based program sponsored by Cambridge Health Alliance, the last fully public hospital institution in Massachusetts. Tufts CHA is a network of 12 primary care clinics and 3 community hospitals with the explicit mission to serve their diverse and complex patient population. They aim to cultivate a passion for health equity and deliver the training needed to provide excellent care across a spectrum of primary care, population health, mental health, and substance abuse.

The majority of physicians at Tufts CHA are primary care physicians and their infrastructure has been built to support it with state of the art electronic medical record systems, population management tools, robust translation services and a dedication to community as well as individuals' health.


 

Thank you for taking the time to speak with us today.

I'd like to start by asking what do you think are the emerging educational issues for training primary care providers in integrated behavioral health (IBH)?

Some of my work requires an integrated behavioral health approach to optimally support patients in chronic pain and those with substance use disorders.

For patients with chronic pain, its truly a biopsychosocial illness and requires a corresponding approach. Chronic pain is often exacerbated by daily life stressors, such as work, financial difficulties, and marital problems. Thus, primary care providers’ role in helping treat patients with chronic pain needs to extend beyond the focus of pain medications and negotiating treatment. Rather, we should focus on helping them address their underlying coping mechanisms in life and setting shared goals. These will help reset visits, helping the patient accept their pain while still engaging in activities that are important to them. This type of approach often requires training the provider on how to frame these visits and also connecting the patient to integrated behavioral health providers who can provide services like cognitive behavioral therapy (CBT), acceptance commitment therapy (ACT), and biofeedback, all of which have been shown to be effective in treating patients with chronic pain.

I work on an interdisciplinary care team that consults patients with complex pain/addiction-related issues. These primary care providers often ask questions like: how can I optimize this patient’s pain regimen in a safe way? Should I be concerned about addiction in this patient?  How do I get this patient to further engage in their care? Our team is made of primary care physicians, psychologists, addiction psychiatrists, addiction experts, and pharmacists with specialty training around chronic pain.  As a team, we discuss these complex cases with the referring provider present and make recommendations back to the primary care physician. We also provide them with language to use to have difficult conversations, framed around motivational interviewing principles.

In addition to chronic pain, treatment of substance use disorders requires an integrated team-based approach.  At our family medicine residency site, we run group visits for patients who struggle with opioid use disorder and alcohol use disorders. During the weekly one-hour group, they participate in a brief psycho-educational activity focused around their recovery (such as reflections, deep breathing, discussing triggers and how to avoid them). The remainder of their time is spent “checking in “and providing support to one another. At the end of group, they receive prescriptions for Buprenorphine-naloxone (aka “Suboxone”); and some receive monthly IM naloxone (“vivitrol”) injections. Patients report highly valuing this group experience and from a primary care doctor’s point of view, this approach feels much richer.

Most patients with substance use disorders often struggle with psychosocial comorbidities and past traumas. We have found that its beneficial to have a team-based integrative approach. At Tufts we have a designated group of providers who know the patients well: front desk staff, medical assistants, primary care providers, a psychologist, and our addictions nurse all work together to support our patients. As a team, we “run the list” and discuss patients after group-- many require connections to individual psychotherapy appointments, support for housing or food stamps, coordination to a higher level of addictions care, transportation assistance, a “check in” call during the week, etc.  We divvy up these tasks, providing collaborative care in a way that feels important and effective instead of daunting and overwhelming than if a single provider were to “own” all these responsibilities.

This model provides high quality patient care, increases access to care and helps support providers in caring for a psychosocially complex patient population that could potentially lead to feelings of burnout without a robust team-based approach.


 

What is the most promising innovation in IBH training that has caught your attention?

As described above, what I like to call “GBOT” -- group-based opioid treatment--is a model that can be employed in the primary care setting, providing “Suboxone” to patients via a group visit approach.

Primary care physicians already run group visits for various chronic diseases, such as diabetes, weight loss groups, and prenatal care.  In our current opioid epidemic, where only 10-14% of patients with opioid use disorder get the care they need, group visits are great way to increase access to care.  Having a group of interdisciplinary providers that includes primary care physicians, mental health specialists, nurses, front desk staff, and medical assistants all helping in patient care can make this feel truly like a “team sport” and fits nicely within a comprehensive coordinated patient-centered medical home approach to care delivery.  Additionally, this model serves as an opportunity to train primary care residents in team-based care, addiction, and small group facilitation skills. At our site, family medicine residents spend four consecutive weeks rotating through group: observation, facilitation (with feedback), and then leading the psycho-educational component of group, so residents feel well-equipped to run group visits for substance use disorders in their future careers.

Tufts recently involved a primary care-based behavioral psychologist to run the skills-building component of our group. They teach patients about topics such as stages of change and motivation, how to identify and “ride out” triggers, managing anxiety and insomnia, smoking cessation, etc.. This not only benefits our patients but also models expert level therapeutic support and motivational interviewing for others to learn from.

Finally, having a dedicated addiction nurse to serve as the true “glue” of the operation makes the GBOT model feasible for busy primary care providers. Our nurse fields patient phone calls, triages patients, and is their first point of contact. The nurse forms a deep and supportive connection with patients and serves as an advocate.


 

What are some of the most pressing challenges for educational programs?

Clinically, we need resources. Especially when working with a population of patients who are underserved and have complex psychosocial comorbidities. These patients oftentimes need a social worker, complex care manager, or therapist more than they need me as the primary care provider.  My role is, in fact, quite limited without the support of these other providers. For example, addiction sits at the base of Maslow’s hierarchy—i.e., it has to be addressed before patients are capable of engaging in any other level of care, such as acute, chronic, and preventive issues.

I am fortunate enough to work in a clinic with behavioral care partners and integrated psychologists that take “warm handoffs.” When I’m seeing patients in clinic who require more behavioral health support, such as patients with active suicidal ideation or significant stress or anxiety.  I can page one of my colleagues who immediately develops a safety plan, coaches the patient and/or connects them to more longitudinal support. We also have social workers, patient resource coordinators, and complex care managers who can help patients navigate the system, assist with housing and transportation, coordinate appointments, conduct home visits, and engage in patient education.

From an educational standpoint, it’s super important to train our future physicians how to work together effectively on teams.  Hence having a clinic infrastructure that embraces team-based care provides residents with experiential learning opportunities. But, this also needs to be partnered with more formalized training in team-based care. Just because physicians know how to manage patient care does not mean they have the skillset to collaboratively lead team-based care models. At our residency training site, several of our faculty have additional training in systems change management, team-based care, and quality improvement and are thus able to role model and teach didactic skills around these topics as well as mentor and provide feedback to resident learners.

When it comes to my particular passions around addiction, it is a topic that has not traditionally received much focus during medical school or residency training. Most physicians do not feel adequately trained to diagnose and treat addiction, and many residency training sites now lack faculty champions in this arena. Having trained faculty in a clinical and educational culture that supports patients who struggle with substance use disorders is key for widespread patient care. At our residency program, our program director understood the essence of this principal and has made chronic pain and addictions core components of our curriculum.


 

What are insights you would like to share for programs new to the field?

Here are some lessons I’ve learned while building the pain and addiction curriculum for our residents.

Lesson #1:

Change attitudes by:

a. Treating addiction as a social determinant of health: Freedom from addiction is foundational to providing further medical care. When patients struggle with addiction, it will be nearly impossible to engage them in further medical care until their addiction is treated.

b. Treat addiction as a chronic disease: It is not a moral failing or behavior problem.  It must be treated like other chronic diseases (hypertension, diabetes, and depression), addressing both physiological and behavioral components.

c. Create culture change within your training site: While most physicians treat patients with pain, most physicians are not certified to treat patients with opioid use disorder. All faculty members should be role models for residents and students in caring for patients with addiction.

Lesson #2:

Partner experiential learning with more formalized didactic learning.  At our site, we expose residents to all levels of addiction care: detox, inpatient/residential, intensive outpatient programs, and our outpatient group visit model.  Residents also attend a methadone clinic. This is partnered with a robust didactic curriculum that includes SBIRT training, urine drug toxicology interpretation, naloxone training, management of opioid use disorder, alcohol use disorder, and tobacco use disorder, and management of chronic pain.  All residents also get buprenorphine-waivered.

Thank you again for taking the time to speak with us today!

To find out more about the Tufts University Family Medicine Residency Program go to their website. 


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