An Interview with Johnathan Goree, MD
Director of Chronic Pain and Opioid Stewardship
University of Arkansas for Medical Sciences
NaRCAD Training Alumnus
by Kristina Stefanini, Program Coordinator at NaRCAD
NaRCAD: Thanks for talking with me today! Can you tell me a little bit about yourself and how you ended up in pain management?
Johnathan Goree: I’m from Arkansas originally. After completing college at Washington University in St. Louis, medical school and residency at Cornell, and a pain medicine fellowship at Emory, I was recruited to start the chronic pain division at the University of Arkansas for Medical Sciences – 2 miles away from where I went to high school. I’m proud to work in Arkansas; Arkansas is such a poor and rural state, so we don’t often have the resources that other states have.
I went into anesthesiology because I wanted to be the best prepared doctor for an emergency, but I moved into pain medicine because I missed the 1-on-1 patient contact and longitudinal patient care. Here are some other things that lead me into pain medicine. After getting my wisdom teeth removed, I was given too much fentanyl during the procedure resulting in being given Narcan to wake up.
That was the first time in my life I experienced 10/10 pain. It allowed me to understand how pain can completely dominate someone’s consciousness. I am also passionate about pain management in minority communities. Many in those communities feel that their pain is undertreated, and evidence backs that up.
NaRCAD: As a physician, what are some of the barriers that detailers may have talking to clinicians about pain management? How can these be navigated?
Johnathan Goree: Every physician will say the number one barrier is time. While most physicians are excited to learn about anything that will improve patient care, unfortunately, physicians are usually not in control of their schedule.
NaRCAD: How can clinicians act as champions in an academic detailing campaign?
Johnathan Goree: One way physicians can help is with the crafting of educational materials. Physicians know how physicians think and can help by crafting a message that may better catch attention.
Another is by dedicating time to answer follow-up questions from detailers and other clinicians. In my field of chronic pain management, detailers that don't have a clinical background may not know how to answer questions on specific off-label situations or treatment of specific pains. A follow-up visit or call with a clinician can help with that.
NaRCAD: Anything else you’d like to add for our readers?
Johnathan Goree: More praise for you guys – your course is excellent! Really understanding the science and method behind academic detailing made me excited to be a part of it. I hope more physicians engage both as detailers and as champions. I think it’s really important.
Johnathan Goree, MD, Director of Chronic Pain and Opioid Stewardship
University of Arkansas for Medical Sciences
Board certified in anesthesiology and pain medicine, Dr. Johnathan Goree received his Bachelor of Arts in biology from Washington University in St. Louis. He then moved to New York City where he completed both his medical degree and a residency in anesthesiology at the Weill College of Medicine at Cornell University. Following his time in Manhattan, he completed a fellowship in chronic pain medicine at Emory University Hospital in Atlanta, Georgia. In 2014, Dr. Goree returned home to Little Rock, Arkansas to join the faculty at University of Arkansas for Medical Sciences where he serves as the Director of the Chronic Pain Division and an Assistant Professor in the Department of Anesthesiology. He primarily focuses on the treatment of chronic pain conditions using opiate sparing, minimally invasive techniques. His specific research interests include complex regional pain syndrome, neuromodulation, and the effects of opioid education initiatives on patient outcomes.
Director’s Letter: Fall 2016 | Mike Fischer, MD, MS, Director of NaRCAD
When the leaves start to turn here in Boston, we know it’s almost time for NaRCAD’s International Conference on Academic Detailing. This year’s 4th annual conference features several new and exciting sessions we’re excited to share with our community.
#NaRCAD2016 highlights the work of innovators in academic detailing from many locations and organizations, ranging from large national health systems to small independent programs.
Diverse clinical topics will be featured at our interactive sessions, including pediatric developmental screening, smoking cessation in patients with serious mental illness, opioid misuse and overuse, screening for ADHD, and many others.
Breakout sessions offer attendees a chance to work closely with leaders in the field, featuring in-depth and hands-on exploration of specific elements of academic detailing. Whether your focus is on training detailers, preparing clinical topic materials, or program evaluation, our dynamic breakout sessions offer a chance to network and acquire new skills.
Our conference is our largest event of the year, but our team has been busy this fall with other activities. At our Boston-based training in September we welcomed trainees from organizations across the country, all of whom concentrated on learning the techniques of academic detailing.
We also spent two days this fall in San Francisco, working with the city’s Department of Public Health on an intervention to increase the use of pre-exposure prophylaxis (PrEP) for patients at risk of contracting HIV. We’re excited to continue supporting our partners at the SFDPH as they move forward on this important initiative.
Come join us at #NaRCAD2016! There’s only a month left to register, and space is limited. Check out our conference hub archival page to see what previous events were like, including on-demand video and program highlights. We’re excited that clinical outreach education has been such an effective strategy to address the pressing problems facing patients, clinicians, and health systems.
This year, we know that the opportunity to learn, share ideas, and connect with experts will continue to ignite inspiration for our community’s important work in improving quality of care and patient outcomes in 2017 and beyond.
Michael Fischer, MD, MS | Director, NaRCAD
Dr. Fischer is a general internist, pharmacoepidemiologist, and health services researcher. He is an Associate Professor of Medicine at Harvard and a clinically active primary care physician and educator at Brigham & Women’s Hospital. With extensive experience in designing and evaluating interventions to improve medication use, he has published numerous studies demonstrating potential gains from improved prescribing. Read more.
NaRCAD: Hi, Meagan and Mindy—thanks for taking the time to talk with us about your clinical outreach education programming at Colorado ABCD. Can you give us an overview about ABCD and its mission to improve child development?
Meagan Shallcross: Colorado Assuring Better Child Health & Development (ABCD) works with community partners, pediatric healthcare providers, early learning providers, and families across Colorado communities. The goal is to strengthen systems and identify children with developmental delays, connecting them with community services as early as possible.
NaRCAD: Tell us a bit about your backgrounds. How did you each get into healthcare improvement?
Meagan: My background in public health, along with experience working in clinical settings and behavioral science research, developed my interest in healthcare improvement that aims to bridge community work and clinical practice, standardize clinical workflows, and ultimately improve experiences and outcomes for patients and families
Mindy Craig: My path to healthcare improvement is a little different than what you might expect. I worked for Northwest Airlines as a flight attendant for several years straight out of college. At that time the airline industry was losing a large amount of money and needed to find a new way of operating. They decided to utilize a Total Quality Management approach and enlisted people from every department to undergo training in TQM and then facilitate small departmental groups in quality efforts. It was through this process that I began to understand the importance of doing business with a quality framework.
Eventually, I left Northwest and started working in a Neurology clinic while going back to school with the goal of becoming a PA. After completing my degree I worked in primary care settings for about 10 years. I participated in small clinic QI efforts over the years and continued to be interested in quality improvement.
I was hired by ABCD 8 years ago to bring a clinical perspective to their physician outreach. It was a natural progression for me to start approaching our work at ABCD with a quality improvement framework. The power of engaging front line staff to implement changes that result in improvement remains as strong as it was when I worked in the airline industry.
NaRCAD: Talk with us about your academic detailing programming at ABCD—you’ve been doing this for about 10 years, right?
Mindy: We started our work encouraging the use of standardized developmental screening tools in the primary care settings. This was supported by the American Academy of Pediatrics policy statement in 2006 recommending the use of these tools at well child visits. We offered informal outreach to physicians providing instructions on screening tools, billing information, AAP recommendations and information on referral resources.
We quickly recognized that screening alone wasn’t sufficient and began talking about the referral process and how to ensure successful referrals were being made. At around this time, research was showing us that only about 50% of children referred for Early Intervention services were actually connecting to that referral. It was easy to identify children with concerns but not as easy to ensure they received needed support.
We decided to try formalizing our approach to outreach by offering Continuing Medical Education [CME] credits. While we didn’t change content, offering CME changed the way providers saw us as detailers. We appreciated the new credibility, but still struggled with recruiting new practices.
NaRCAD: Recruiting practices to participate is a challenge for many programs. How did this struggle transform into quality improvement?
We now offer Quality Improvement [QI] and MOC projects for implementing developmental screening, autism screening and postpartum depression screening in addition to a project that aims to increase the percentage of children who successfully connect with Early Intervention when referred from their primary care provider. We have been thrilled with the response from physicians for participating in these projects and just received funding to continue and grow our outreach efforts.
NaRCAD: What have been some other challenges you’ve faced when going in to talk to clinicians about implementing developmental screening?
Mindy: I started working at ABCD unsure of how to provide physician outreach, so I naturally modeled my efforts on the one successful approach I knew very well, which was pharmaceutical sales. As the recipient of pharmaceutical detailing, it was pretty easy to begin my outreach efforts in a similar fashion. I quickly learned how it feels to be a detailer. Front office staff rejected me repeatedly, I made hundreds of phone calls that didn’t get returned, and when I did get to speak to a provider I had to speak quickly and to the point to keep their attention. The challenge of gaining access was the biggest barrier I confronted early on and remains at the top of the list.
NaRCAD: When dealing with those challenges, what’s helped you to build relationships with clinicians in order to gain commitment?
Meagan: To deal with the challenges that arise, we have found that it helps to get creative in our approach to gain access to clinicians and add credibility to our messages. A barrier we have encountered when trying to schedule times to meet with clinicians is the expectation that we will provide food. Our funders and budgets do not allow us to pay for food, so we have opted to provide other incentives for clinicians, such as CME or MOC credit. Not only is offering CME/MOC credits an educational incentive for providers, but it lends credibility to our messages. We facilitate our QI projects through multiple meetings at the practice and have found that, by developing relationships and a presence in the office, we can overcome clinicians’ resistance to implementing screening or other changes in their practice.
NaRCAD: We were happy to see you at our 3rd International Conference on Academic Detailing here in Boston a few months ago. Tell us more about how the conference helped you think about your work in a different way.
Mindy: We were thrilled to be able to attend the conference and came away very energized. We highly recommend the conference to anyone doing similar work. Some of our key “take-aways” were around the fundamentals of academic detailing, including the need for profession materials and repeated visits to develop relationships. We came home committed to find money for developing professional materials and to attend the two-day intensive training offered by NaRCAD.
However, I’ve struggled with our role as a non-profit in meeting these needs. Up to this point, ABCD has utilized a very hands-on approach. We plan meetings, take notes, write up PDSA cycles, make “To Do” lists – anything we can do to make the process easy for the practice and allow the providers to concentrate on patient care. A true practice facilitation model is more concerned with increasing the capacity of the practice to continue quality improvement work after the facilitation had ended. The goal isn’t to do all the work, but to help the practice find capacity to do it themselves.
NaRCAD: What other advice would give to a new and emerging AD program that’s just getting started, or that you’d give yourself if you could go back in time 10 years?
Meagan: We have found NaRCAD’s training and tips to be very helpful, so we would recommend that new clinical educators attend a NaRCAD techniques training to hone their skills in communicating their messages with clinicians and gaining commitment to behavior change. One of our main takeaways from the NaRCAD conference was the importance of high-quality, professional materials, so we would recommend that new programs budget for the development of professional materials as well as food, which can be an incentive when setting up meetings with clinicians.
Over the years, we’ve realized how critical it is to work with community partners before going into healthcare practices to ensure that clinical workflows, such as processes for making referrals to external agencies, are aligned with community-defined processes and so that clinicians are aware of the resources available to patients and families in their communities.
NaRCAD: Thanks so much for sharing important insights from your program to improve childhood health outcomes. We look forward to seeing you at a future training and hearing more about your program's future successes!
Mindy Craig, PA-C, M.S., Director of Physician Outreach, has been with the ABCD team for 8 years and brings with her experience in the clinical setting. She earned her physician assistant degree at the University of Colorado Health Science Center’s Child Health Associate/Physician Assistant program in May 2000. Concurrently, she completed additional course work and research to earn her Master of Science degree in Pediatrics. Ms. Craig worked as a physician assistant in a number of settings for ten years prior to joining the ABCD team. Her medical career has included a variety of medical office positions from medical records clerk to practice manager. This range of experience positions her to fully understand the unique dynamics and flow in a typical office, which allows her to deliver technical assistance to practices at a meaningful level.
Ms. Craig’s quality improvement experience began in the business sector where she was extensively trained on Total Quality Management (TQM) at Northwest Airlines. She worked at the airline as a facilitator, training inflight and ground personnel in the principles of quality improvement. This experience with quality continued in the clinical setting, as she has participated in and/or chaired a number of quality improvement projects over her career as a physician assistant. In addition to her work at ABCD, Ms. Craig also does consulting work for organizations needing assistance with physician outreach and education.
Meagan Shallcross, MPH, Healthy Steps/Physician Outreach Coordinator, joined the ABCD team in June 2015 as the Healthy Steps and Physician Outreach Coordinator. Meagan is passionate about building systems and environments that support children’s healthy development through clinical-community partnerships and integrated care delivery approaches. Meagan earned a Master of Public Health degree at the University of Michigan, where she supported Patient and Family Centered Care projects at the university health system and was involved with community-based participatory research addressing health equity, as well as research focused on provider-patient communication.
Learn more at www.coloradoabcd.org. All photos used with permission.
Highlighting Best Practices
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