An interview with Brandon Mizroch, MD, MBBS, Provider Network Supervisor, Louisiana Department of Health
by Anna Morgan, RN, BSN, MPH, NaRCAD Program Manager
NaRCAD: Thanks for chatting with us today, Brandon! We’re excited to be catching up with you. Can you tell us about your program at the Louisiana Department of Health and the work you’re currently doing?
Brandon: Absolutely. I was hired to do work around PrEP and PEP, detailing providers across the state of Louisiana, in 2017. Since then, my role has expanded and I promote education for providers about syphilis, congenital syphilis, and Hepatitis C. Our department now has 3 detailers, including myself.
Louisiana became the first state in the country to undergo an incredibly revolutionary Hepatitis C Elimination Plan, which has caused my detailing focus to shift. There’s been huge advancements in the drugs that treat Hepatitis C, but they’ve been inaccessible to much of the population due to cost. We negotiated a fixed rate price for Hepatitis C treatment and can now treat 100% of the population, compared to the 3% of the population we could treat previously. There’s been a big push to identify and train providers who’ve never previously treated patients with Hepatitis C. I’ve been leading the charge by getting the word out, running symposiums, and working with the marketing team that’s creating our statewide campaign.
NaRCAD: Wow, that sounds like innovative and exciting work. Can you explain your program’s approach a bit more?
Brandon: I try to blend a few different approaches together. I attended the NaRCAD training during my first year as a detailer. NaRCAD built the foundation of detailing for me. I always use the NaRCAD methodology to get my foot in the door and identify providers who can be champions within their practices. I find it much easier to follow up and do longer didactic sessions about complex clinical topics when I use the techniques of academic detailing during my first face-to-face visits with providers.
I connect with about 20 providers in this 1:1 model each month. I also work with residency programs, hospital systems, and present at Grand Rounds to expand my reach. There’ve even been instances where I’ve attended dinners for physicians that are hosted by pharmaceutical companies to network and identify new clinics that would benefit from detailing.
NaRCAD: We’re happy to see that you’re blending academic detailing with other approaches. Do you provide follow-up to providers after your visits?
Brandon: Follow-up is incredibly important, no matter what approach is being used. I like to send an email after each visit that includes digital resources for both providers and patients. I also offer providers the ability to call, text, or email me because of the apprehension that exists around topics where the knowledge base is still growing. Maintaining relationships with providers also ensures that we have a strong provider network that we can continue to educate on other clinical topics down the road.
NaRCAD: Building a connection with providers is imperative, especially as you move into different clinical topics. Your program spans the entire state. Do you find that there’s a difference when you provide clinical outreach education in rural vs. urban communities?
Brandon: Yes, there’s certainly a difference. The providers in urban areas tend to have a higher knowledge base when it comes to PrEP and syphilis, perhaps due to marketing efforts or higher patient loads. This makes starting the conversation a bit easier. Additionally, urban communities have access to navigators, who help with non-medical aspects, like transportation issues, lack of health insurance, and long commute times that all prevent folks from getting the treatment they need. Providers in urban areas are also busier and easily distracted during 1:1 visits, which can make detailing a bit difficult.
On the other hand, rural communities are quite the opposite. Providers tend to have more time in their schedules and are excited to sit down with somebody from the state office. They’re eager to learn, but there’s typically less of a knowledge base, making it slightly more difficult to start the conversation.
I’ve also learned about patient barriers as well, which affect access and provider care. Patients in rural areas are often friends or family with those throughout the community, including those who work at clinics. The notion that you would know the receptionist or provider at a clinic is enough to deter folks from seeking medical care around a topic like sexual health. To encourage access, our state has created a TelePrEP program that offers PrEP services to anyone via telemedicine. Consultations take place over the phone, labs are obtained at third party lab companies, and medications are mailed right to the front doors of patients. It was originally created to help folks in rural communities who face stigma-related barriers, but we’ve expanded the program across the entire state of Louisiana. It’s a great referral service that I can share with providers.
NaRCAD: It’s wonderful that you’re able to identify these challenges and have resources and tools to address them. What’s one piece of advice you’d give to folks who are detailing on a similar clinical topic or have a large geographical region to cover?
Brandon: It’s important to have several different ways of presenting information to the providers you’re detailing and to use varied approaches depending on the barrier(s) they’re facing. I typically focus on emotional connection, financial concerns, and the evidence and science behind the key messages I’m delivering. I’m also ready for provider resistance, and am prepared to address it, which is something I learned from NaRCAD.
When it comes to detailing over a large and diverse geography, it’s always necessary to plan ahead. My general rule of thumb is that however many hours it takes to drive to a location, that’s how many providers I want to meet with while I’m there. I typically try to use larger educational events, like meetings with clinics over lunch, as my anchor point for longer trips. After I have that scheduled, I search for smaller clinics around the area where I can meet with providers 1:1. It’s all about maximizing your time.
Brandon Mizroch received his MD/MBBS from the University of Queensland/Ochsner Clinical School Program in November of 2016. Since taking over as the PEP/PrEP Provider Outreach Specialist at the Louisiana Department of Health in August, 2017, he has worked with hundreds of doctors statewide on HIV prevention best practice. Since then he has expanded his educational base and now serves as the head of the academic detailing department at the Louisiana Department of Health, Office of Public Health, STD/HIV/Hepatitis program. As the Provider Network Supervisor he has helped lead the provider Outreach for the state’s first-in-the-nation Hepatitis C Elimination program. From grand rounds presentations at LSU-Shreveport Hospital and Baton Rouge General, to state-wide symposia and conferences, to one-on-one counseling encounters at dozens of clinics all over Louisiana, he has helped spread awareness and education on HIV prevention, syphilis screening and treatment, and HCV screening and treatment through evidence-based care.
An interview with Tony de Melo, RPh, Director of Clinical Education Programs, Alosa Health
by Anna Morgan, RN, BSN, MPH, NaRCAD Program Manager
NaRCAD: Tony, thanks for chatting with us today about your role at Alosa Health! What’s been the most exciting part of the work that Alosa has done this year?
Tony: Our partnership with Aetna, a managed health care company and health care insurer. We’ve been working with them to provide educational outreach to providers on chronic pain, acute pain, and opioid use disorder (OUD); supporting them in managing pain using non-opioid drug options; appropriately dosing opioids when they need to be used; tapering down patients who are on existing high doses of opioids; and helping to identify patients that may have opioid use disorder. We’re now working in Pennsylvania, Virginia, West Virginia, Ohio, Illinois and Maine.
NaRCAD: That collaboration does sound exciting! Now, let’s talk a little about your role at Alosa. You actively detail, you manage academic detailers in the field, and you lead trainings at Alosa. Which aspect of your role is your favorite, and why?
Tony: When I’m training and managing detailers, I see myself more as a coach than a trainer. I’ve always liked educating and teaching—I enjoy helping others develop their skills and seeing them improve. Training folks and coaching them in the field is rewarding to me because I feel that I’m impacting what they’re doing in their own communities. It brings me happiness to see others succeed.
NaRCAD: As a coach, how do you know when your work has been impactful?
Tony: When I work with detailers in the field, I can see firsthand that they are able to be impactful with the providers because they are bringing about behavior change with their message delivery and confidence. We can also measure how impactful our work is by reviewing our Salesforce data. I can see from the detailer’s visit notes when providers have agreed to a behavior change, and this is a true measure of our work being impactful.
NaRCAD: With success comes challenges. What are some of the major challenges you see academic detailers face in training and in the field?
Tony: The major challenge is teaching detailers to have a conversation with clinicians rather than a lecture. Making the visit more conversational doesn’t often come as naturally as presenting the information in a lecture format, but the conversation must be about understanding where the provider is now, what their needs might be, and how to deliver content to make behavior change.
In the field, the major challenge is access to providers. Many health systems have regulations and restrictions for those who want to meet with providers, because representatives in the pharma industry have bombarded and overloaded providers throughout the years. As a result, we’re often seen as an outside influence or an outside visitor, so we aren’t always given the opportunity to meet with a provider.
NaRCAD: With these challenges in mind, how do you instill confidence in academic detailers as a trainer and as a manager?
Tony: We spend a lot of time practicing and providing feedback during trainings. We practice individually, with partners, and with outside folks who are playing the role of providers. Practicing multiple situations, multiple times, over multiple days, builds confidence. We also videotape the trainees so that they can see what they’re doing well and what they can improve upon.
As a manager in the field, it’s quite similar. I usually sit down with each detailer after a visit and discuss what worked well and what they could do differently in their next visit, so that each visit becomes a learning opportunity. Providing feedback and being a mirror for the detailers helps them to build confidence and skills as time goes on. I also offer the detailers my perspective; having spent time doing this myself and observing others, I can share the tricks, skills, and wording I’ve heard throughout my time with the detailers.
NaRCAD: Those are all great ways to build confidence among detailers. What’s one piece of advice that you would give to academic detailers?
Tony: Don’t be afraid to ask for a specific behavior change, and remember to follow up to make sure that the behavior change occurs. One thing that I find to be hard for academic detailers is the “ask”, where detailers are asking for commitment or behavior change from a provider at the end of the visit. I always tell detailers to frame it as, “based on what you’ve heard today, what is one thing you’d do differently?” Follow-up then ensures that providers are committed to change and holds them accountable for what they said they would do.
NaRCAD: That’s extremely helpful advice for detailers. What’s the best thing a program manager could do to maintain high levels of engagement among detailers?
Tony: As a manager who’s coaching or guiding others, it’s important to build trust between yourself and the folks you’re coaching or managing. It can be lonely when you’re in the field detailing by yourself, so managers need to have touchpoints with their detailers. Building trust and having your detailers know you’re all working together helps them stay self-motivated; it makes them want to go out into the field and do a good job because they know someone is backing them up.
NaRCAD: Thank you for taking the time to chat with us today. We value your unique perspective on detailing, managing, and training!
Tony de Melo manages field staff and leads academic detailer trainings at Alosa Health. He attended Massachusetts College of Pharmacy and Health Sciences in Boston, where he received a BS in Pharmacy with a minor in Business Administration. This business interest led him to work for several pharmaceutical companies as a sales representative, account manager, training manager, district/regional manager, associate director of managed markets training, head of sales training, and development & marketing product manager. He has also worked for smaller businesses that were looking to grow their sales and marketing programs. Throughout his career, Tony has successfully sold, marketed, trained, led, designed, developed and executed solutions to meet business objectives.
Director's Letter | Mike Fischer, MD, MS, Director of NaRCAD
As NaRCAD enters its 10th year as the only national resource center dedicated to clinical outreach education, we’re ready to take our collaborations with you to the next level. The strength and sustainability of NaRCAD has grown from the hard work we’ve done together with you, our community members in the field.
We’re committed to continuing to provide the technical assistance you need to make your programs innovative, efficient, and successful. As we kick off 2020, our entire team at NaRCAD invites you to join us in leading our field forward through strategic partnerships, resource-sharing, and peer learning, all to implement important initiatives that will have a significant impact on clinicians and their patients.
The nature of our role as a resource center has continued to grow in parallel with increased recognition of the importance of academic detailing as a strategy to address multiple clinical challenges. We’ve been especially excited to see the effectiveness of AD enhanced when aligned with other initiatives to improve the quality of care.
Responding to this growing demand, we’ve dramatically expanded our reach, conducting 20 trainings in 15 different states across the US in the past two years alone, and 2020 looks to be no different. With the increased demand for AD technical assistance, we have a busy year ahead of us, from capturing your successes and sharing them via our DETAILS Blog to training your detailers to be ready for field work (and troubleshooting challenges along the way.)
Along with continued trainings across the US to improve opioid safety in partnership with states supported by the CDC’s Overdose Data to Action (OD2A) grants, we’ll also continue the important work of training new detailers to educate clinicians about using HIV PrEP to reduce the risk of new HIV infections, also through CDC-funded programming.
We’re equally excited to have launched a new CDC research grant in collaboration with the Oregon Health Authority to rigorously evaluate the impact of their OD2A intervention and to develop a model for pragmatic assessment of similar efforts in other states. If you’re also interested in evaluating the impact of your AD program, reach out and let us know—we’re eager to hear from you.
Although we have been conducting more trainings recently, we see the demand for them continuing to grow at an even faster pace. As we grow, so does our core team, and all of us are dedicated to amplifying the impact of the important work you do. We’re already starting to plan for NaRCAD2020, our 8th annual conference, and we invite you to consider submitting your ideas and innovations when we start accepting submissions on March 1, 2020. But you don’t need to wait until then—we’re here to offer you customized support to strengthen your program, as you plan for success in 2020 and beyond.
Happy New Year!
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.
An interview with Jennifer Pruskowski, PharmD, BCPS, BCGP, CPE, a palliative care pharmacist at University of Pittsburgh, School of Pharmacy by Winnie Ho, Program Coordinator
Overview: This intervention is taking place in the University of Pittsburgh Medical Center (UPMC) Senior Communities in Pittsburgh, Pennsylvania. Dr. Pruskowski's work is funded by The Beckwith Institute.
NaRCAD: Hi Jennifer, thank you for taking the time to speak with us today! You are breaking new ground on a deprescribing academic detailing project in Pittsburgh. What role does deprescribing play in improving health outcomes in nursing homes?
Jennifer: Deprescribing is the identification and discontinuation of potentially unnecessary or inappropriate medications. What I really love about deprescribing is that it’s really patient-centered.
For example, one medication class might be appropriate for one patient, but maybe not for the next. Within the UPMC Senior Communities, I have developed, implemented, and evaluated a clinical pharmacy-driven deprescribing initiative named the DE-PHARM Project, which stands for the "Discussion to Ensure the Patient-centered, Health-focused, Prognosis-appropriate and Rational Medication regimen". Say that 5 times fast!
This project allows pharmacists within the nursing home setting to review medication regimens and conduct conversations with nursing home residents, their families, and their caregivers. Deprescribing allows us to rebalance the equation when there may be medication overload, and helps us to reduce the burden on our patients.
NaRCAD: What are unique factors when approaching deprescribing work in nursing homes?
Jennifer: While a lot of patients outside of the nursing home are complex, the nursing home population is one of the most obvious and at-need, due to their reduced functional status and their need for additional services. Nursing home residents also tend to receive their care, essentially, from one provider. So, it’s very conducive for deprescribing, and it allows us as an academic detailing program to overcome one of the main barriers to deprescribing, which is tracking down and contacting potentially numerous prescribers.
NaRCAD: That's a pretty common barrier, to track down and identify the multiple providers that are supporting the patient.
Jennifer: Absolutely. The other thing to consider is that there are already regulations in place within a nursing home setting that encourages deprescribing. Every nursing home that receives Medicare or Medicaid has certain regulations to follow, which is basically all of them. For example, since the mid 2000’s, there’s been verbiage around ‘gradual dose reduction’ for anti-psychotics, and then in the last 5 to 7 years, this was expanded to antimicrobials as well to try to curb growing antibiotic resistance.
Nursing homes are built for deprescribing, in the sense that these medications are continuously monitored and every quarter, they need to justify to CMS why someone is on a medication at a certain dose.
However, what gets challenging is integrating care goals, functional status, patient perspectives, and evidence-based literature into deprescribing. Nursing home settings often times have a comfort-focused treatment plan. The medications that I tend to focus on when encouraging deprescribing may not be the same as other detailers. For example, many detailers are working on opioid-related campaigns. Opioids are crucial for deprescribing, but if you think of a patient who is closer to the end of life, opioids are typically not what we target because the medication tends to align with their treatment plan and goals.
NaRCAD: That’s a really interesting and complicated situation. What are some of the other challenges you’re facing with approaching deprescribing in nursing homes?
Jennifer: One of the big challenges is that no studies have been done about the initiation of certain medications in nursing home residents. Most clinical trials are also done in healthier, younger adults. We don’t have the most literature to guide a lot of what we do, and it’s critical because our prescribing goals are going to be different for the nursing home population as compared to the general population.
NaRCAD: This can often be a challenge when initiating an academic detailing campaign in a field that may not have as many other detailers. One of the foundations of academic detailing is the dissemination of evidence based information, but as you mention, there are not as many resources and studies in the work you’re about to partake in.
As you and your team begin to initiate your program, how do you plan on approaching this paradox?
Jennifer: So, the first thing that we’re doing is determining the medication that we’re going to target. We’re taking a look at prescribing cultures within the nursing homes that we’re targeting, and our working group is looking at what medication regimens are potentially inappropriate, or deprescribing eligible.
There is an evidence-based algorithm that we utilize for our intervention based on what medication class we will target from deprescribing.org, run by Barb Farrell, a friend and colleague of mine in the Canadian Deprescribing Research Network. So for some medications, such as proton pump inhibitors or histamine blockers, there are resources that have been created.
However, as we do the groundwork for our program, we could potentially find ourselves targeting a medication class that doesn’t have a lot of evidence-based literature around it, and then that will be both the challenging and fun part of developing verbiage and guidelines around that.
NaRCAD: Someone’s always got to do it first! It can be difficult getting programs started, and we are very lucky to have a growing population of people who are interested in integrating academic detailing into their programs.
As you’re reflecting and planning for the future, what would be important for someone else in your shoes to know about starting a new program?
Jennifer: The most important part is really thinking through the needs assessment. We know that there is a problem, and now it’s about identifying the specific issues and critically thinking through a solution. We will really need to understand the prescribing behaviors that exist in our nursing homes. Much of the prescribing culture there is based off inertia, extrapolation, and people doing their best to adapt important regimens from information that doesn’t directly address their unique situations with nursing home residents.
We are trying to see if, for example, our providers are prescribing certain medications because they see this problem a lot in other populations they work with, or if they are working off of knowledge that has not been updated in many, many years. These would be two very different academic detailing interventions.
NaRCAD: And finally, as we begin a brand-new decade in 2020, what would you say to anyone else looking to consider academic detailing?
Jennifer: Jump in! Academic detailing is a proven intervention to effectively disseminate evidence-based literature. I would say that as much as academic detailing can feel like a one way street – as a detailer coming to give a provider information – it really is more of a two-way street than people think. I think in the small amount of time that I’ve done this, I feel like I’ve actually gotten more information from our prescribers than I feel like I’m giving to them at the end of the day.
NaRCAD: A fantastic note to end on. Thank you so much for taking the time to speak to us, and we wish you and your team continued success in 2020!
Dr. Pruskowski received her PharmD from Wilkes University in Wilkes Barre, Pennsylvania. She then completed a Post-Graduate Year One Pharmacy Practice and Post-Graduate Year Two Geriatric Residency from the Williams Jennings Bryan Dorn Veterans Affairs Medical Center in Columbia, South Carolina, as well as an Interprofessional Palliative Care Fellowship at the James J. Peters Veterans Affairs Medical Center in Bronx, New York.
Dr. Pruskowski is a Board Certified Pharmacotherapy Specialist, a Certified Geriatric Pharmacist, and a Certified Pain Educator, and has received specialized training in pain management from the American Society of Consultant Pharmacists and the American Society of Health-System Pharmacists. Her clinical practice site is the University of Pittsburgh Medical Center (UPMC) Palliative Supportive Institute (PSI) as the Palliative Care Clinical Pharmacy Specialist.
An interview with Rachel Lemons, Project Manager, ONE Tennessee
by Anna Morgan, RN, BSN, MPH, NaRCAD Program Manager
NaRCAD: Thank you for taking the time to speak with us today—we’re excited to hear about you and your team! Can you tell us a bit about ONE Tennessee and how your organization first became involved with academic detailing?
Rachel: ONE Tennessee is a state-wide nonprofit healthcare collaborative who is focused on fighting the opioid epidemic. We were founded as an outcome of a summit hosted by the Tennessee Department of Health called “Turning the Tide.” The summit joined together healthcare professionals and stakeholders to discuss best practices for tackling the epidemic. Academic detailing was highlighted as a best practice during the summit and it was collectively decided that it would become one of our initial projects. ONE Tennessee brought the academic detailing pilot program to life through the opioid crisis funding the Department of Health received from the Centers for Disease Control and Prevention.
NaRCAD: We’re glad to know that the strategy of AD was highlighted! You’re now managing a program of detailers focused on opioid safety across the state of Tennessee—tell us what that’s like.
Rachel: Exciting! Once our detailers were trained by your team, my role was very much supportive in nature. I helped our detailers to identify clinicians in their communities, and troubleshoot any issues. We were fortunate enough to be able to recruit a passionate group of pharmacists for our pilot, and that made my job easier from a clinical standpoint, since they’re the subject matter experts on opioid prescribing. They‘re on the front line of the epidemic, and they fit the perfect mold for engaging with clinicians to build a strong and trusting relationship.
NaRCAD: You recently completed the pilot stage of your program. What would you say are some of the biggest lessons you’ve learned so far about building an academic detailing program?
Rachel: Getting in the door was one of the biggest barriers our detailers faced. From a programmatic standpoint, I think ONE Tennessee could have done a little more foundational work for our detailers, like speaking with our stakeholders and educating them on academic detailing as it relates to the opioid initiative—that would have really helped our detailers gain access to clinicians.
We also learned that time was a barrier for our detailers. Our initial grant period was only one year, and things moved very quickly. We recruited full-time community pharmacists, so having the bandwidth to prepare and complete academic detailing visits was often difficult, especially if there was limited employer support.
NaRCAD: Those are all familiar challenges across many of the programs we support. How did you maintain strong relationships with your detailers and support them in the work that they were doing in the field?
Rachel: I always had an open line of communication with our detailers. We had standing monthly webinars, but it was difficult to find a time that worked for everyone because they were full-time pharmacists. Our detailers were scattered across the state and were mostly in rural areas, so I was not able to meet with them in person; however, I was available via email, phone call, and text message. I learned early on that I had to meet detailers where they were. Some detailers did not have time to check email, so it was easier to do a quick call at lunch or early in the morning before their day got started. It really depended on the needs of the detailer, but I always maintained an open line of communication.
NaRCAD: That’s a great model, and regular communication helps detailers feel a sense of community through a project. Other supports are often more concrete, like tools and resources. What are some that you've found to be critical to program success, and why?
Rachel: I think first and foremost, our partners, specifically NaRCAD, the Tennessee Pharmacists Association, the Tennessee Hospital Association, the Tennessee Nurses Association, the Tennessee Medical Association, and the Tennessee Department of Health, were a tremendous resource that made our program incredibly successful. Google’s platform (Google Drive, Google Sheets, and Google Docs) was also critical to our success, as it allowed us to share data and updates in real time. We did not have access to specific evaluation tools because we are a young organization and our grant period was only one year. Our shared space online helped me to stay organized and capture information from our detailers all in one place, and it was free!
NaRCAD: These are all great reflections for AD program managers to learn from. Based on the successes and challenges of this pilot, where do you see your program in a year?
Rachel: I see us continuing our current model with our inaugural group of academic detailing community pharmacists while working towards designing, developing, and implementing a “train -the -trainer” model in partnership with your team. I also see us having discussions with large and small hospital systems to customize plans to fit their unique needs related to opioid safety. Most importantly, we want to continue to support the state and our other healthcare stakeholders who are with us on this journey.
NaRCAD: We’re happy to help support that vision. Any other important advice/tip that you’d give to other young programs?
Rachel: Patience. You must have an understanding that there are going to be pitfalls, but if you have the support and the right people involved, your program is going to succeed. Also, don’t try to reinvent the wheel if you don’t have to. There are so many other programs out there — reach out to people and have conversations!
NaRCAD: Rachel, thank you so much for sharing your experiences with us. We're excited to see the impact of your program into the future.
Rachel Lemons found passion for public service early on in life. She is committed to assisting those with the greatest need in her community. She’s working to effect change socially and through public policy. She is a graduate of East Tennessee State University, where she received her Bachelor of Science in Public Health. Her involvement with Tennessee’s Opioid Epidemic began with the Department of Health, where she was exposed to the State’s rapid response in this fight which lead her to joining ONE Tennessee as a Project Manager. She continues to build her career with a practical and wide ranging set of experiences in order to gain a global perspective on health issues facing communities today. Rachel is an active member in the Junior League of Nashville, Tennessee Public Health Association and currently serves as the Board Intern at Cheekwood Estate & Gardens in Nashville.
Please refer to our Conference Hub page through narcad.org for all conference related videos and slides, which are available as of December 2nd, 2019.
by Anna Morgan, RN, BSN, MPH, NaRCAD Program Manager
Our team at NaRCAD was proud to host the 7th International Conference on Academic Detailing on November 7th and 8th, 2019 in Boston to a sold-out crowd of health professionals engaged in clinical outreach education. With this year’s theme emphasizing collaboration and innovation, our Director, Dr. Mike Fischer, kicked off Day 1 of NaRCAD2019 by reflecting on the past decade of NaRCAD’s work, while also discussing our exciting plans for the future, and highlighting the importance of enhancing connection between attendees to support their work ahead.
Dr. Melissa Christopher, National Director for the Veteran Affairs (VA) Academic Detailing Services, was next to take the stage as the Day 1 Keynote Speaker. She provided the audience with an overview of the current work by the Department of Veterans Affairs National Academic Detailing Service and how it supports a High Reliability Organization culture. She also spoke of the future of academic detailing at the VA, which includes expanding their reach with virtual detailing (“e-detailing”) and advancing their electronic health records through ordering safety alerts and real-time PDMP data.
Other day 1 highlights included an expert panel presenting on the successes and challenges of implementing e-detailing within their programs, sharing stories and insights about when, why, and how to connect virtually with providers. Our small group breakout sessions explored the fundamentals of academic detailing, with sessions focused on the basics of an academic detailing visit, how to identify and apply the most reliable sources of evidence-based research, and how to successfully lead an academic detailing program.
Day 1 also included our annual “lightning round” of Field Presentations, a session that highlights aspects of recent academic detailing interventions. Topics included the use of academic detailing to improve maternal and neonatal health through safer opioid prescribing, the effects of academic detailing on pediatric antipsychotic prescribing in the Medicaid population, and increasing access to Nalaxone in New York City through academic detailing. The afternoon also included a talk on Aetna’s opioid strategy and ongoing initiatives, with a focus on leveraging provider and system relationships to incentivize physician engagement and catalyze behavior change.
Dr. Jerry Avorn, Co-Director of NaRCAD, ended the Day 1 presentations with his Annual Academic Detailing Talk, addressing the importance of moving beyond the silos that exist in most healthcare settings, and how academic detailing can encourage the integration and collaboration of roles and initiatives to create synergy. That collaboration and synergy was illustrated during our evening’s Networking Reception, where we launched our new Mentor Match Program to great success, pairing those just starting out in the field with mentors who are part of more established programs.
Day 2 provided similar opportunity for exploration and dialogue about program expansion. We kicked off with Keynote Speaker Tupper Bean, Executive Director from the Centre for Effective Practice (CEP). He discussed CEP’s journey to sustainability as an independent, not-for-profit organization, and reminded the audience that sustainability is a parallel process, not an “add-on”. To further explore sustainability, our Day 2 Plenary highlighted capacity-building strategies, best practices, and opportunities for expansion in clinical outreach education programming.
Day 2 Field Presentations provided opportunities to learn about more active AD programs, including topics such as identifying barriers to opioid prescribing through academic detailing, a team-based model and approach to AD, and a new AD campaign exploring cannabis as an alternative tool for patients experiencing pain. Our afternoon wrapped up with workshops focused on relationship-building for program sustainability, understanding stigma when supporting patients with opioid use disorder (OUD), and building AD campaign materials with limited resources.
We’re grateful to all those who attended, and beyond the 2 days of connection at the conference, we at NaRCAD are committed to creating continuous opportunities for connection, support, and collaboration among all of you who make up our incredible network. Keep an eye out for our Annual Community survey, which we’ll send you in early December to find out what you need as you make an even greater impact in 2020!
-The NaRCAD Team
The genius of the American health care system is its fragmentation. And by ‘genius,’ I mean evil genius, or demented genius. And sadly, also ‘very stable genius,’ since that awful fragmentation has been stubbornly resistant to change. It’s a great way to maximize revenue and expenditures, but not the best way to provide care to patients – and it leads to much of the poor care and unaffordable costs that we face.
In many organizations caring for patients over 65, their medication use is stripped away into Medicare drug benefit plans separate from the way the rest of their clinical care is paid for and organized. Many payors in the private and public sector carve out the use of drugs for specific conditions, removing it from the organization and payment for the care of the illnesses those drugs treat.
Outside integrated health care systems, in many settings the content and costs of prescribing decisions live in a pharmacy silo separate from ambulatory care, which itself is often a world apart from inpatient care, with all of these sectors de-coupled from assessment of clinical outcomes and patient satisfaction. But sick people don’t come in silos, and the drugs we prescribe for them drive hospitalization and other clinical outcomes and the enormous human and economic costs of both.
Academic detailing can help pull these domains together in a way that can make medical care more person-based and evidence-based, as well as more cost-effective. The AD interventions that work best start from the global perspective of the practitioner: how to diagnose and care for a given clinical problem, whether it’s Alzheimer’s disease, diabetes, or incontinence, rather than focusing narrowly on simple medication use questions (“Don’t prescribe Drug X; Drug Z isn’t on the formulary”).
This holistic approach is what clinicians and patients need and want, and the one most likely to bring about optimal care decisions. Such a “beyond the drug silo” approach also has implications for the content and focus of the printed clinical materials our programs use, as well as the interactive approach employed by the outreach educator in these programs.
Focusing on silo-busting can also help the academic detailer be seen as a valued colleague helping the clinician improve overall patient care, rather than as a nag, a busybody, or a scold. And as the US health care system continues its slow transition away from the evils of fragmentation to a more rational approach that focuses more on integration of care and less on widget-based revenue maximization, the comprehensive, clinical outcome based vision of academic detailing will increasingly help to pull all the pieces back together where they belong.
Want more? Peruse the archive of Jerry's pieces here on DETAILS.
Jerry Avorn, MD, Co-Director, NaRCAD
Dr. Avorn is Professor of Medicine at Harvard Medical School and Chief of the Division of Pharmacoepidemiology and Pharmacoeconomics (DoPE) at Brigham & Women's Hospital. A general internist and drug epidemiologist, he pioneered the concept of academic detailing and is recognized internationally as a leading expert on this topic and on optimal medication use. Read more.
An interview with Zack Dumont, BSP, ACPR, MS, a clinical pharmacist with the RxFiles Academic Detailing Service in Regina, Saskatchewan, Canada and a NaRCAD Training Facilitator
by Winnie Ho, NaRCAD Program Coordinator
Overview: The Cannabis Act went into effect in Canada in October of 2018. The legalization of a drug with strong potential for a myriad of clinical uses was followed by many questions from patients and providers alike about its effectiveness, its safety, and lack of previous research. The RxFiles have carried out a cannabinoid academic detailing campaign to address the demand for truth in a time where research has just begun to shed light on previous myths, misconceptions, and clinical promises.
NaRCAD: Zack, thank you for taking the time to speaking with us today! RxFiles has been around for more than 20 years. What do you do you believe is driving the demand for the resources that academic detailing is providing?
Zack: There’s an element of doubt in the information out there, because people have experienced misinformation before. People are often interested in the truth and that’s one of the most amazing things about academic detailing. There is also a desire for practical information that can be used to actually treat patients, and there’s a ton of overlap there. These things are important to these very, very busy providers who want the best for their patients.
NaRCAD: We know that your team is working on a cannabinoid campaign, which can be a nebulous topic. Can you discuss a little more about cannabinoid policy and conceptions in Canada?
Zack: We’re coming up on the one-year anniversary of recreational marijuana legalization, but medicinal cannabis has been legal for about two decades. With the legalization of recreational cannabis though, we’re seeing fairly rapid change in perceptions of what the truth is. It’s tough to keep up with.
With academic detailing, it was challenging to decide how to tackle it – can we just talk about the medicinal cannabis side? Or do we have to dive deeper? When we dug into it, it became clear that we also had to talk about the recreational side. For example, the people we provided our services to also wanted to know, “if I decline my patient cannabis prescriptions, what will they be able to get on their own?”
NaRCAD: Did RxFiles choose to launch its cannabinoid campaign with the passage of the Act, or has this been planned for a longer period of time?
Zack: It’s coinciding with our work on pain, following our work on pain and opioids. In addition, because legalization was approaching, the providers had more questions because their patients were asking about cannabis as an alternative to opioids.
NaRCAD: How have provider responses been to the cannabinoid campaign so far?
Zack: It’s welcomed. Our information is usually welcomed. There’s some frustration over how little information there is out there. While frustrating, I think it’s kind of comforting to know that we’re not that far behind. It’s kind of mixed, but at the same time, they’re still happy to get information from a trusted resource. There's a lot of gray area information right now because it's a newer field.
NaRCAD: Right now is a shifting and transformational time, especially with something like cannabinoids with a distinct history of stigma and legalization, even with all this new interest. As an academic detailer, how do you source your information knowing that there isn’t enough research out yet and a lot of gray area information? How do you begin to build a campaign around a topic like this?
Zack: The evidence pyramid gives us the best approach for practical information, for people who are the interface of care. You want to find high quality, synthesized information. Whether its osteoporosis or COPD or pain or cannabis, you start with the guidelines and figure out what kind of information they are providing. We started with some recently published guidelines and it was a synthesis of systematic reviews, and made an attempt to summarize all the evidence of where cannabis was found to be of benefit. We also reviewed the bibliography with all the primary literature and metanalyses.
This process is pretty similar for any academic detailing topic. The other process is going to the people we provide services for, and asking what their patients are asking to treat with cannabis. They tend to ask about cannabis for pain, insomnia, or for things like tremors and that gives us some guidance in terms of what kind of literature we want to find. Of course, we are also looking into what the key messages are in the information we find and distribute. With cannabis, the interesting thing was the lack of information on the different conditions it could be used for. In some ways, it was easier, as weird as it sounds. We didn’t have as much reading to do on that topic.
NaRCAD: Is there any advice you would give any other academic detailing organizations considering this topic for a campaign?
Zack: One, you’re going to have your conversations about stigma. There isn’t a perfect picture of who uses cannabis and it could be absolutely anyone. You’ve got to have the conversation about stigma and get to know your own biases.
In the same vein, we thought about how important word choice and language is. We thought about whether or not we call it cannabis, marijuana, pot, or cannabinoids. Do we call it a medication or a product? All of those words and the considerations that we’ve given opioids - do we call them "addicts", or is it "dependence", and what are the differences between addiction and dependence? The third piece would be that you’ve got to talk to your providers in your local area and find out what their main questions are.
Your job is to provide a service, and if you can find out what their wants and needs are, you’ll provide a far more satisfying service for them and could establish strong relationships that you can build on. There will be a lot of information out there and you will need a lot of leads to help you sort through it all. This won’t be the last time we're addressing this.
NaRCAD: Thank you for taking the time to speak with us, and for leading the charge in bringing cannabinoids to the conversation about treatment for pain.
Zack Dumont is an clinical pharmacist with the RxFiles Academic Detailing Service in Regina, Saskatchewan, Canada and a new expert facilitator for NaRCAD's training courses. He has been involved with the RxFiles since 2008, with experience in both academic detailing and content development of RxFiles’ evidence-based drug therapy comparison tools. Zack maintains clinical practices for inpatient internal medicine, with more specialized experience in anticoagulation and heart failure. His professional interests include teaching evidence-based medicine, knowledge translation, development of clinical decision supports, collaboration, and leadership.
Zack graduated as a Pharmacist from the University of Saskatchewan in 2008. Following graduation, he completed a hospital pharmacy residency with the Regina Qu’Appelle Health Region, where he currently serves as a Clinical Support Pharmacist, with involvement in training new staff, precepting pharmacy residents and undergraduate students, and providing clinical support to various health region committees and working groups.
An interview with Dr. Rosemarie Parks, District Health Director, Ware County Public Health Department
OVERVIEW: Ware County, Georgia, was one of 2 sites selected for year 2 of a pilot program of the CDC (Centers for Disease Control and Prevention), NACCHO (the National Association of County and City Health Officials), and our team at NaRCAD (The National Resource Center for Academic Detailing). This exciting pilot program focused on community-level work with local public health departments to develop customized interventions to reduce opioid overdose and death. Six sites experiencing significant public health problems related to opioids were selected over the two years to be trained in academic detailing; those trained health professionals then conducted 1:1 field visits with front line clinicians to impact behavior around prescribing, treatment referrals, and patient care, all within a rural area. As year 2 comes to a close, we’re showcasing stories from the field.
NaRCAD: Thanks so much for joining us to share how your detailing project has gone in Ware County, Georgia, Dr. Parks. Can you talk to us a bit about how the opioid crisis has presented itself in your community?
Rosemarie: Our agency serves 16 counties in Southeast Georgia, and we have seen the same things across all of these counties. The opioid crisis affects the community across the board; in every sector. Law enforcement is seeking the effects of this crisis, so is healthcare, and people that work with children and families. They all acknowledge that they’re seeing it in their day-to-day work. So many public health topics only affect one sector, but this opioid crisis affects them all.
NaRCAD: With it affecting so many, did you think the strategy of academic detailing would lend itself to improving patient health in response to the opioid crisis in Ware County?
Rosemarie: Being a clinician myself, I did initially see how academic detailing would be a good public health intervention. I thought academic detailing would make the lives of providers better by providing them with evidence-based information and resources. As we discussed during the training with NaRCAD, there’s so much information out there, and it’s really difficult to sort through all of it.
In public health, we’re facilitators, data people, and information sharers. I really believed AD would work when I saw the statistics about Ware County during the 2-day training. Ware County is the highest prescribing county in the state, and the 12th highest prescribing county in the nation. Those statistics are eye-opening, and I believed that would make detailing successful in Ware County by raising awareness of how the opioid crisis is impacting our own community.
NaRCAD: You mentioned being a clinician—you’re also the Public Health Director for your district. How does being both a clinician and the Public Health Director make it easier for you to be successful as a detailer?
Rosemarie: My position allowed me to easily make appointments, and I did not have difficulties getting in the door, like so many other detailers do. I often had visits that were a lot longer than the usual 15 minutes, because clinicians would set aside more time to talk to me. My clinical experience as a primary care physician in private practice for many years made is so that I could relate to the clinicians, and allowed for more honest sharing. I would tell other doctors what worked and didn’t work for my practice, and that made them more comfortable opening up about their own experiences.
NaRCAD: That’s excellent—this is an example of how pre-existing relationships and a fusion of both experience in clinical care as well as public health can really merge to encourage change. What else was unique about your detailing experience?
Rosemarie: Another thing that was unique in Ware County is we did both 1:1 visits, as the original model suggests, as well as group visits. There were many occasions upon which multiple providers and key leadership from a health system were all together in one room. This allowed providers to hear from other providers, and I saw that as a critical dynamic. The conversations continued well after those visits ended, and still continue to this day. It was also important that key leadership was present because they heard exactly how the issue is impacting clinicians and patients, and they have the power to make decisions affecting opioids in their health system.
NaRCAD: It’s great to hear that a group education approach worked so well. What would you say has been the most impactful piece of this intervention?
Rosemarie: I think academic detailing for the opioid crisis worked so well in Ware County because public health is seen as a neutral entity, and because of that, we were able to effectively facilitate these discussions. We do a lot of work in the healthcare community but it is rare that the public health department takes the time to visit an individual practice or provider. During my visits, I witnessed clinicians take in the data about how Ware is one of the highest prescribing counties in the nation, and saw how it immediately encouraged them to want to make a change.
After answering initial questions about where the data came from, clinicians were open to discussing things in more detail, and were consistent in enacting the CDC’s opioid stewardship recommendations, especially consistently using the PDMP. It also gave clinicians the opportunity to express concerns and challenges they face in their daily practices.
NaRCAD: We’re so glad academic detailing has been impactful in your community. What has the greatest challenge been with implementing a successful academic detailing intervention to improve opioid safety in Ware County?
Rosemarie: The overall experience has been fantastic. As we discussed, the providers were really open and honest. For me personally, as a detailer, it was difficult not to feel like I needed to be the one who had all the answers. I handled this by being a link to information, rather than having all of the information myself.
For instance, when a clinician asked a question, or requested a resource I didn’t know about, I’d say something along the lines of, “Let me do some research about that, and when I come back I’ll be sure to have that information.” It helped when I was able to give the disclaimer that “I’m by no means the expert, but I’ve learned a tremendous amount about opioids and the crisis, and I’m here to share some of that information with you. And if I don’t know the answer to something, I can find someone who does.”
NaRCAD: That’s a great way to handle that kind of situation, and academic detailers are indeed the connector to resources, and certainly don’t need to know all of the answers. Well-handled! And speaking of not knowing all the answers, what is something you wish you knew prior to joining the LOOPR Academic Detailing project?
Rosemarie: Personally, there were no big surprises. Everyone did a great job in explanting the process, executing the training, and providing resources. Like anything though, you don’t really get the hang of it until you get those first few visits under your belt and become more comfortable. Overall, this has been a great experience. It was so helpful having additional resources, learning from people that are highly knowledgeable and respected in this field, and being able to share experiences across all LOOPR sites with other detailers who are doing the same work.
Dr. Rosemarie D. Parks serves as the District Health Director for the Southeast Health District (District 9-2, Waycross, GA). She has overseen the 16 county health departments, 3 wellness clinics, and over 50 programs since moving to rural Georgia from Ohio in 2005. Dr. Parks holds a Master of Public Health degree from Youngstown State University, Ohio, and a Medical Doctorate from the Northeastern Ohio Universities College of Medicine. She is board certified in internal medicine. She is also a member of the National Association of County and City Health Officials.
As the District Health Director for the past 14 years, Dr. Parks has overseen telemedicine and teledentistry projects that have expanded new technology to meet the ever-growing needs of a rural population. She has also worked diligently with community partners in planning to combat the opioid epidemic and strategized for innovative solutions to meet the public health needs of the community.
Recruiting Pharmacy Students for Academic Detailing: Reflecting on Successes and Challenges in Boone County, West Virginia
OVERVIEW: Boone County, West Virginia was one of 4 original site selected for years 1 + 2 of a pilot program of the CDC (Centers for Disease Control and Prevention), NACCHO (the National Association of County and City Health Officials), and our team at NaRCAD (The National Resource Center for Academic Detailing). This exciting pilot program focused on community-level work with local public health departments to develop customized interventions to reduce opioid overdose and death. Six sites experiencing significant public health problems related to opioids were selected over the two years to be trained in academic detailing; those trained health professionals then conducted 1:1 field visits with front line clinicians to impact behavior around prescribing, treatment referrals, and patient care, all within a rural area. As year 2 comes to a close, we’re showcasing stories from the field.
Via NaRCAD, NACCHO, & the CDC’s pilot project, “LOOPR”, we were able to connect with high-burden counties across the U.S. whose rates of high prescribing and high fatal and non-fatal overdoses identified them as a county in need of support. NaRCAD worked on the implementation of an academic detailing initiative over the course of 2017-2019 with Boone County, located in rural West Virginia.
Boone County ranks as the 22nd most vulnerable county across all counties in the United States, with the highest drug overdose mortality rate of all counties in West Virginia. Due to these and other data, Boone was identified as a key county in which to test the implementation of an academic detailing program, in which trained detailers would speak to clinicians and pharmacists about safer prescribing of opioids, checking the state’s prescription drug monitoring program to avoid dangerous co-prescribing of opioids and benzodiazepines, and to try and provide treatment, non-opioid therapy, and resources to patients in need.
One of the most unique approaches across all 5 sites of the LOOPR Project was carried out in Boone, with the team of 5 detailers being hand-selected from the nearby University of Charleston West Virginia’s School of Pharmacy. Four of these five recruited detailers were students in training to become pharmacists; one detailer works at the university as a professor of pharmacy. Selecting pharmacy students and faculty allowed for many positive approaches to the project, as well as creating unforeseen challenges.
Programs considering hiring student detailers can often rely on the flexibility of students’ schedules, as well as an enthusiasm and energy for learning that may exist in smaller quantities later in one’s career, when full-time roles in healthcare take priority. While many career-established clinicians may have little room in their schedules to squeeze in 1:1 sessions with fellow clinicians, students may have more of an ability to shift their schedules, especially if they are not yet carrying out residency.
a reflections from Boone County’s Detailing Team, it’s clear that best practices in detailing should also consider the vast amounts of new information that students are absorbing early in their learning careers, and that learning clinical content may take longer to grasp. In addition, the comfort level with new clinical information may lead to less confidence in discussing best practices, especially with clinicians whose careers are much more established. Finding the right balance of tenacity, communications savvy, more time to ramp up to comfort in delivering and leading 1:1 sessions, an additional amount of technical assistance provided at more frequent intervals, and additional practice time or shadowing time with a mentor, can all benefit student detailers who are training to join a clinical outreach education team in a high burden area.
With these elements in place, a student detailer may be poised for success—however, other considerations include the fact that students may have new projects, graduation pending, or life events which may end up limiting their ability to dedicate consistent time to a project rolled out over many months.
Other reflections from the Boone County AD Team included looking carefully at the social climate in which AD interventions of this nature may be implemented. While no county is free of potential clinician-level or community-level stigma, particularly around issues such as opioid use disorder, Boone’s AD team shared a particularly challenging setting within which the local community was not as supportive of evidence-based harm reduction initiatives as would be beneficial. One detailer’s suggestion to raise the visibility of and advocacy for harm reduction included considering a public health campaign prior to a detailing campaign, to ensure that subsequent roll-out of detailing is more sustainable and met with an openness from clinicians to consider behavior change.
NaRCAD’s work with the public health department in Boone County, in partnership with the students and faculty of University of Charleston, West Virginia, provided the kinds of insights critical to learning from a pilot project of this nature. As with many pilot studies, any information gathered can illustrate a clearer picture of the landscape within which public health initiatives can be implemented, so that future projects may have a greater impact. With many thanks to the student and faculty team of Boone County’s Academic Detailing Project team, we and our partners are grateful to have learned so much over the past two years.
Building Accountable Relationships: Critical Conversations on Opioid Safety with Clinicians in Bell County
An Interview with Lutricia Woods, RN
OVERVIEW: Bell County, Kentucky was one of 4 original sites selected for years 1 + 2 of a pilot program of the CDC (Centers for Disease Control and Prevention), NACCHO (the National Association of County and City Health Officials), and our team at NaRCAD (The National Resource Center for Academic Detailing). This exciting pilot program focused on community-level work with local public health departments to develop customized interventions to reduce opioid overdose and death. Six sites experiencing significant public health problems related to opioids were selected over the two years to be trained in academic detailing; those trained health professionals then conducted 1:1 field visits with front line clinicians to impact behavior around prescribing, treatment referrals, and patient care, all within a rural area. As year 2 comes to a close, we’re showcasing stories from the field.
NaRCAD: Hi Lutricia, thanks so much for taking the time to speak with us about your work as an academic detailer for the opioid crisis in your community. Can you talk to us about how the opioid crisis has presented itself in Bell County, Kentucky?
Lutricia: There’s not a family in this community that hasn’t been touched by the opioid crisis in some way. Twenty years ago, I worked in hospitals as an RN discharging patients and providing them with their prescriptions as they prepared to go home. At the time, I was shocked at the rates of prescriptions of opioids with benzodiazepines, and patients thinking it was safe. From my perspective, in our community, the opioid crisis really began by doctors beginning to prescribe many opioids to their patients without education or an understanding of the dangers.
Three years ago, I was working on a project at a middle school, and was surprised by the number of grandparents that were raising their grandchildren because their children were either in jail, or otherwise affected by opioid use disorder [OUD]. In Bell County, we also have so many people unable to find a job because they cannot pass a drug test, and once that happens, they return to use because of the stressors of not being able to find a job and pay their bills, and it becomes a challenging cycle to overcome.
NaRCAD: Thanks for sharing your perspective, Lutricia—it can be true that some clinicians don’t see the impact of their role in prescribing opioids, and many times may believe that people who develop an opioid use disorder do so because of a moral failing, rather than seeing it as a medical issue. Did you think 1:1 outreach, provided directly to prescribing clinicians, would lend itself to improving patient health in response to the opioid crisis in this community?
Lutricia: I desperately hoped it would. The opioid crisis is very personal to me, as it is to many people in our community. Years ago, my mom had 2 surgeries within 6 months. She had complications from one of those surgeries, and as a result, she was in the hospital for 6 weeks, during which time her care providers did not wean her off of the opioids she took immediately after the surgery. She returned home with prescriptions for opioids at a high dosage, and she developed opioid use disorder.
My mother’s doctor, with whom I worked, reached out to have a conversation with me. He told me that I had to be the one to intervene with my mother because she continued requesting more opioids. I conveyed that I wanted her to discontinue taking them, and that he needed to assist us in finding a way to do this, as I felt his prescribing without discussing safety caused the initial issue. His response was that he wanted to “keep her happy.”
My mother struggled for the rest of her life; she was able to completely wean off and discontinue using them, but it required a lot of counseling. As a result of this experience, I became a drug education coordinator, as I really wanted to do my part to mend the opioid crisis by providing drug education for every student in the county. And then, of course, I became an academic detailer for this project over the course of the past 2 years, which involves clinician education about safety and risk of opioid prescribing.
NaRCAD: Thank you for sharing that Lutricia; the opioid crisis is personal to so many of us. What would you say has been the most impactful piece of this academic detailing intervention as you went into the field and spoke with clinicians?
Lutricia: The most impactful piece has been the ways in which we’re trying to hold clinicians accountable for their roles in the crisis, as well as leveraging their ability to improve things based on their relationships with their patients. For many of the doctors and nurses I met with, our conversations and educational resources have made them more thoughtful and intentional about their role. They seem to realize more that they have the power to decrease the number of prescriptions they write, the length of time for which they write them, and talk more with their patients about safety.
NaRCAD: That’s fantastic. What about the most challenging part of this project—what’s been hardest about meeting with clinicians to talk about the opioid crisis in Bell County?
Lutricia: Getting an appointment to go in and meet with these clinicians has been so frustrating and challenging. I always say that the receptionists in doctors’ offices are the most powerful people in the world. If you can’t get through them, you’re not going to get what you need, and it is the same with the patients. I couldn’t even get in to see my husband’s doctor, who we’ve known since we were kids. My husband had an appointment, so I resorted to going with him, and did a detailing visit on the spot with his doctor. This same doctor ended up changing practices, and it’s been a lot easier to get into that practice—all because of the office manager. Those relationships are important.
NaRCAD: Getting in the door is definitely a consistent challenge across many programs. We’ve heard from other detailers that practice makes perfect, and sometimes it’s easier to gain access when you actually show up and request a meeting in person. What else did you learn after being in the field?
Lutricia: When I was “volun-told” that I would be attending a training, and doing “academic detailing”, I didn’t truly understand what it was or what the impact would be. I’m a big picture person, and I couldn’t see the big picture at all; I went into that training not knowing what to expect. It wasn’t until I actually started making visits that I could start to see the seeds we were planting to begin to have an impact.
Share your thoughts on this piece in the comments section below, or learn more about the LOOPR project and other opioid safety academic detailing initiatives here and on our Detailing Directory.
Guest Blog Interview: David O’Riordan, MPharm, MPH, PhD
Senior Pharmacovigilance Officer
Pharmaceutical Care Research Group
University College Cork, Ireland
NaRCAD: Thanks for speaking with us, David! Tell us a bit about your professional background in healthcare, and how you became involved in academic detailing.
David: I am a pharmacist by training, and a couple years ago I decided to carry out a PhD in Clinical Pharmacy at the University College Cork. As part of the PhD, I completed a systematic review examining how pharmacists can be utilized to optimize prescribing in primary care, including through academic detailing. After finding NaRCAD’s resources through a Google search, I registered for the NaRCAD conference in Boston. Dr. Fischer, Dr. Avorn, and all the other attendees at the conference were very encouraging.
I left the conference determined and enthused to lead an academic detailing intervention back home. Dr. Avorn and Dr. Fisher put me in touch with Eimir Hurley, a PhD scholar in Ireland, who formerly worked in academic detailing at Alosa Health, and who ended up being a great help in executing the intervention.
NaRCAD: That’s terrific—it sounds like you had a great team at your disposal to begin this work. Can you tell us a little about the unique characteristics of the Irish health system?
David: Ireland has a public and private health system. Public patients are more likely to wait longer for appointments. Private insurance is a substantial cost to individuals, though. The health care system is quite fractured unless you’re a private patient. Pharmaceutical drug representatives are also allowed to visit primary health practices here.
NaRCAD: In April, you published a study titled “Pharmacist-led academic detailing intervention in primary care: a mixed methods feasibility study” in the International Journal of Clinical Pharmacy. Why did you choose urinary incontinence as a clinical topic?
David: As this was a feasibility study, I decided to use one topic as part of the intervention. I organized a meeting with a group of general practitioners (physicians) who would be involved in the academic detailing intervention. The topic of urinary incontinence was chosen by the physicians because they highlighted that it was a topic not discussed regularly among themselves, and currently their only source of information is provided by pharmaceutical drug representatives.
NaRCAD: What barriers to success did you come across in your feasibility study?
David: For this project, I was the only academic detailer. I started detailing after going to the two-day Basics Academic Detailing Training in Boston in May 2016. In some cases, during the roll out of the intervention I found it difficult to get past the practice manager, but luckily I had learned strategies on getting in the door in Boston that were useful in my effort. On a few occasions, the practice managers didn’t follow through on connecting me with the physicians. I got around this by utilizing physicians I knew in other practices to gain access to their practice. A lot of it came down to how well you know the physicians. I was lucky that they trusted me when I spoke to them. When I did get to meet with physicians, they all seemed very enthusiastic.
NaRCAD: Can you talk a bit more about how receptive physicians were to academic detailing?
David: Absolutely! This was a mixed methods study, so my colleague Eimir Hurley carried out focus groups after my detailing sessions to evaluate the feasibility of the intervention. Eimir conducted the focus groups on my behalf to reduce bias. The physicians liked that I wasn’t from a pharmaceutical company and that the sessions only lasted 10-15 minutes. They liked that local physicians had chosen the topic, and I wasn’t coming with my own agenda.
NaRCAD: How are you or others going to use your feasibility study results to implement across the country?
David: I am currently not involved in academic detailing, but I hope to be again in the future. If someone from another part of Ireland read my paper, they would recognize that physicians are very willing to take part in academic detailing. From my experience physicians didn’t feel threatened and really enjoyed the interaction. They liked the interactive style of the visits, and the way that that the evidence was delivered. My study provides a platform for other researchers to detail to a wider group of physicians in Ireland.
NaRCAD: Anything else?
David: I am very grateful for the NaRCAD team for providing the academic detailing training. I knew literally nothing about academic detailing, and through meeting their team members Sarah Ball, Amanda Kennedy, Mary Liz Doyle-Tadduni, and others, I felt encouraged to go back and detail. I was the only person from Ireland at the training, and the NaRCAD team gave me some useful feedback. I really enjoyed academic detailing, and I was especially proud when my paper was published. I discovered there is an appetite for this educational intervention in Ireland.
David O’Riordan, MPharm, MPH, PhD
Senior Pharmacovigilance Officer
Pharmaceutical Care Research Group
University College Cork, Ireland
David holds a Masters in Pharmacy (MPharm), Masters in Public Health (MPH), Post Graduate Certificate in Teaching and Learning in Higher Education (PG Cert) and a PhD in Clinical Pharmacy.
He has extensive experience as a community pharmacist. He previously worked as a Lecturer in Clinical Pharmacy in University College Cork (UCC). While there, he contributed to and assisted in the delivery of research-led teaching at undergraduate and postgraduate level. He also supervised on a number of research projects. He was a clinical trials pharmacist involved in the Thyroid Hormone Replacement for Subclinical Hypo-Thyroidism Trial (TRUST). This was a randomised placebo controlled clinical trial comparing levothyroxine to placebo in community dwelling older adults (≥65 years) with subclinical hypothyroidism (SCH). He is also a tutor on the Irish Pharmacy Union (IPU) Academy. This educational initiative was developed by the IPU to support pharmacist engagement with Continuous Professional Development (CPD). He is currently the Senior Pharmacovigilance Officer at the HRB-Clinical Research Facility, UCC.
As we reflect on the two major public health topics we’ve been focusing on as we’ve traveled to public health departments across the United States, we’re learning that the public health detailers we’ve been training are discussing much more than just evidence with the clinicians they’re meeting. When we train new health educators on the methods of interactive, 1:1 education, we’re asked most often to customize our curriculum to cover two of the most highly stigmatized topics today: the opioid crisis, and HIV prevention. As the topic of stigma has come up at every straining we’ve implemented this year, our training team has added dedicated time to our trainings to discuss ways to address clinician stigma that arises during 1:1 detailing visits.
So, what, exactly, is stigma? It’s defined as “a mark of shame or discredit,” and appears in numerous ways, including through labeling, stereotyping, discrimination, and social inclusion. One of the biggest myths about stigma is that some people carry it, and some people don’t. However, stigma is not binary, and we all possess the ability to stigmatize another group that we perceive to be an ‘outsider’ group. Historically, stigma has appeared mainly in the form of social inclusion, with those identified as ‘others’ being treated as societal outcasts.
The interactive approach of AD is well-suited to address clinician stigma by creating a space in which the detailer can ask the kinds of needs assessment questions that can identify the source of these stigmatizing perspectives. When a 1:1 visit is facilitated by a skilled clinical outreach educator who is curious about clinicians’ experiences and genuinely wants to help implement sustainable change, many clinicians feel comfortable in sharing beliefs, identifying patterns, and building relationships based on trust and service.
Our language and beliefs will continue to evolve as we continue to learn, encourage one another, and be empathic. We can do this by holding each other accountable in a non-punitive way, pairing our best intentions with education to use inclusive, supportive language, and committing to holding one another accountable by identifying moments when we witness stigma, in order to correct, reflect, and move forward. We’ve seen the potential for change; the medical community’s understanding of substance use disorder and HIV prevention has improved significantly over the past few decades.
Outside of our training settings, where else can we start? We’d very much like to hear from you, our community members, about how you’ve experienced or witnessed stigmatizing behavior as it has occurred within the healthcare setting. If you’re an outreach educator, tell us about a time you’ve seen stigma arise from a clinician’s perspective, and what you thought was behind it. If you’re a patient or a provider, talk to us about ways in which you’ve experienced or carried stigma. Keeping a dialogue open and encouraging sharing is one of many steps towards a connected medical community that embraces its patients, clinicians, educators, and supporters with compassion, clarity, and support.
Thanks for reading, and please share your thoughts and experiences in the comments section below!
The NaRCAD Team
An Interview with Amber Elliot, BSN, RN, Assistant Director, St. Francois County Health Center
St. Francois County, Missouri was one of two sites selected for year 2 of a pilot program of the CDC (Centers for Disease Control and Prevention), NACCHO (the National Association of County and City Health Officials), and NaRCAD (The National Resource Center for Academic Detailing). This exciting pilot program focused on community-level work with local public health departments to develop customized interventions to reduce opioid overdose and death. Six sites experiencing significant public health problems related to opioids were selected over the two years to be trained in academic detailing; those trained health professionals then conducted 1:1 field visits with front line clinicians to impact behavior around prescribing, treatment referrals, and patient care, all within a rural area. As year 2 comes to a close, we’re showcasing stories from the field.
NaRCAD: Thanks for joining us to talk about academic detailing in St. Francois, Amber. Let’s start the conversation with some background information about your county. How has the opioid crisis presented itself in your community?
Amber: As with many other places, St. Francois County has certainly felt the impact from the opioid crisis. We have high rates of overdoses and over-prescribing. There have also been more children in foster homes because their parents have an opioid use disorder, as well as increasing drug arrest rates. Many aspects of our community have been affected in some way or another. I think this is the main reason why so many community agencies have come together to start working on this issue.
NaRCAD: Why did you think the strategy of academic detailing would lend itself to improving patient health in response to the opioid crisis in your community?
Amber: Academic detailing is a great strategy to reach out directly to clinicians in their offices in order to provide resources and supportive education without punitive actions. We really weren’t sure what to expect with having two nurse practitioners, two registered nurses, and a pharmacist carrying out the 1:1 detailing visits.
Health Center administration and detailers were skeptical of how physicians would react to other disciplines “telling them how to do their job”. However, academic detailing isn’t telling them what to do, it’s talking with them about what they can do to keep their patients safe. It is a partnership.
Missouri is the only state without a statewide PDMP. St. Francois County passed an ordinance to join the St. Louis County voluntary PDMP in 2017. The first report from the PDMP showed St. Francois County as the highest prescribing county in the state. This was a big concern for the Local Board of Health and, we learned from community partners, the citizens of St. Francois County. Health Center administration has presented opioid-related health data for the county at various meeting and kept hearing from partners that clinician outreach education and patient education were top priorities when it came to prescription opioids.
NaRCAD: So, it sounds like it’s been a success so far. What would you say has been the most impactful piece of this intervention?
Amber: The greatest success of academic detailing in St. Francois County so far has been the willingness of most physicians to start the conversation about how they can improve prescribing patterns, and care of patients at risk for or experiencing opioid use disorder (OUD). Also, many physicians have started using the PDMP regularly as a result of our academic detailing visits.
NaRCAD: That’s excellent news and shows the impact that 1:1 education can have! Over the course of this pilot project these past 4 months, what has the greatest challenge been with implementing a successful academic detailing intervention to improve opioid safety in St. Francois?
Amber: The challenge are the providers who do not want to talk with the detailers, or the ones who flat out refuse to change their prescribing patterns. As a nurse, this is frustrating to me because I believe in quality, evidence-based healthcare for all. The refusal to learn, or seek to learn, new information about medications that are prescribed daily is poor patient care and our citizens deserve better than that.
NaRCAD: That does sound frustrating! During our 2-day training, we really emphasis the importance of asking open-ended questions to draw clinicians out. However, there will always be some clinicians who will not engage, no matter how great of a detailer you are. Victoria Adewumi from the original cohort of LOOPR detailers discussed that in a prior blog post. What is something you wish you knew prior to joining the LOOPR Academic Detailing project?
Amber: I wish I’d known more about choosing detailers. Recruitment is important. When recruiting detailers, it is more important to make sure to recruit people who have the bandwidth to do the detailing, rather than making sure they have the perfect clinical background. It may be a good idea to create a formalized agreement to ensure they completed their required detailing visits.
NaRCAD: You are spot on, Amber. Recruitment is a complex process. Readers can learn more about this later in the summer when we release our new Implementation Guide to help sites like yours select and hire the right candidates. Readers can read other LOOPR blog interviews here, and stay plugged in for more LOOPR site highlights in the next couple of months.
Amber Elliot, BSN, RN
St. Francois County Health Center
Amber Elliott is the Assistant Director for the St. Francois County Health Center in Park Hills, MO. She received her Associates Degree in Nursing in 2008 from Mineral Area College to become a Registered Nurse. She went on to obtain her Bachelor’s Degree in Nursing in 2011 from Central Methodist University. She has spent most of her nursing career working in acute settings, primarily hemodialysis. Amber started working in public health four years ago in hopes to make her own community a healthier, safer place to live. Amber has been working on opioid-related activities since 2017. She currently resides in Farmington, MO with her husband and two children.
Summer's officially here, and we're excited for what lies ahead in public health, especially when it comes to what clinicians can do to improve their patients' health. Here at NaRCAD, our work encourages front line care providers to think differently when it comes to opioid safety, sexual health and STI prevention, cancer control, reducing overmedication for the elderly, and much more.
For health educators who provide 1:1 outreach to clinicians, NaRCAD provides hands-on, intensive training, so that these educators can make an impact when bringing the best evidence to front line staff. If you haven't been to one of our trainings, we've just opened registration for our September 23 & 24th, 2019 session here in Boston, where you'll spend 2 days with us, learning how to effectively and persuasively communicate with doctors, nurses, and pharmacists, helping them to increase the chances that their patients will have better health outcomes.
Space fills up fast, so register today, and join other health professionals from across the US who are looking to strengthen clinician care in their communities. After the training, you can bring the interactive interpersonal communications skills of academic detailing back to your health system or local health department to roll out interventions to support chronic disease management, substance use disorder, HIV prevention, and many other critical clinical topics.
And if you're already in the field doing this important outreach work with providers, we want to hear from you, and feature you on the DETAILS Blog. Better yet, join us this November 7 & 8, 2019 at our 7th Annual International Conference on Academic Detailing and share your work with our community. Meet others who are advancing the field, infusing clinical care with the best evidence-based tools and approaches in health care.
Want to hear from our community members? And keep your eye on our Twitter feed, and check our News & Media Center for our latest e-news and CoRE Podcasts, or browse the DETAILS archives to the right for more stories from the field.
For our part, we'll be adding new stories this summer on successes and challenges in implementing academic detailing in partnership with our colleagues at CDC and NACCHO to support patients dealing with opioid use disorder and pain management. and we'll be hitting the road to train new detailers in Kansas this August. Stay tuned!
The Team @ NaRCAD
Share your work in public health with us. What's happening in your community around the opioid crisis? HIV prevention? Patient education? Have an idea you'd like to hear more about on our next Podcast? Want to share new ideas or challenges related to public health detailing? Sound off below.
Featuring: Kimberly C. McKeirnan, PharmD, BCACP
Director of the Center for Pharmacy Practice Research, Washington State University College of Pharmacy and Pharmaceutical Sciences
As a pharmacist, I spend a lot of time teaching. I teach patients how to take their medications, how to choose over-the-counter products, and how to identify whether or not to treat minor ailments at home, in the pharmacy, or by seeking care from a physician. I also get to teach other health care providers when one of the medications they prescribe to a patient will interact with the patient’s other medications or cause side effects that will be problematic.
After teaching informally in the pharmacy since 2005 and more formally as a Clinical Assistant Professor for the College of Pharmacy and Pharmaceutical Sciences at Washington State University since 2013, my transition to become an academic detailer was natural.
In 2014 I teamed up with an interprofessional group of colleagues to apply for grant funding to improve the low pneumococcal immunization rates in our local rural areas. Our project proposed utilizing academic detailing to teach healthcare providers about pneumococcal immunizations and the importance of immunizing patients. The CDC Advisory Committee on Immunization Practices (ACIP) released a recommendation to vaccinate all patients 65 and older with the new PCV-13 pneumonia vaccine in combination with the longstanding PPSV23 vaccine as part of a two-dose series.
Having two pneumococcal vaccines with a complicated vaccination schedule has been challenging for providers. I often hear the questions from my colleagues: “Why are there two, do we really need two?”, “Which one do I give first?”, “When do I give the second one?”, and “What if I give them too close together, do they still work?” Additionally, during a needs assessment of our area we found that many rural pharmacies in our area do not vaccinate at all or only stock certain vaccines because they don’t want to cause competition with the local physicians.
We were successfully funded with an Independent Grant for Pfizer’s Learning and Change from Pfizer in 2015. During the first phase of the project, we attended the NaRCAD training program in 2015. The NaRCAD training provided a solid foundation for the framework of our project.
However, once we started talking to local providers about coming in to provide academic detailing, we ran into a major barrier. Getting our “foot in the door” with local providers was harder than we expected. It became clear that our team would need to expand to include more healthcare providers and that we would need to focus our efforts on convincing local medical clinics and pharmacies to invite us in to detail their teams.
We expanded our team to include two pharmacists, one nurse, two physicians, two student pharmacists, one student nurse, two medical students, and on biomedical data analysis student. Our team physicians were able to identify physician champions and convince local medical practitioners that our detailing would be helpful for the medical team. They conveyed the message that we weren’t trying to rearrange things – just offer support the clinics. Four pharmacies and two medical clinics invited us to provide detailing.
For the medical clinic visits, we were able to give 15-minute presentations during staff meetings at each location. Attendees included hospital administrators, practitioners, pharmacy staff, nurses, medical assistants, and front end office staff. We appreciated the opportunity to reach so many disciplines at once since immunizations can be recommended by several different health disciplines and at several points during an office visit or hospitalization.
Our detailing visits were so well received that we were asked to come back to one of the medical clinics to provide a more in-depth educational program to all of the nursing staff. The second clinic invited us back to meet with hospital leadership to discuss specific points where interventions could be implemented, such as using an EHR alert, putting up signs, or simply asking patients if they were interested in receiving an immunization.
We identified several clinical pearls for teams that are considering getting into academic detailing:
McKeirnan KC, Colorafi KJ, Panther SG, Potyk D, McCarthy J. Teaching the Healthcare Team about Pneumococcal Vaccination Practices for Older Adults through Academic Detailing. The Senior Care Pharmacist. Accepted March 2019, in press.
Kimberly C. McKeirnan, PharmD, BCACP
Director, Center for Pharmacy Practice Research, Washington State University College of Pharmacy and Pharmaceutical Sciences
Kimberly C. McKeirnan, PharmD, BCACP, is a Clinical Assistant Professor in the Department of Pharmacotherapy at the Washington State University College of Pharmacy and Pharmaceutical Sciences. Dr. McKeirnan graduated with her Doctor of Pharmacy degree from WSU in 2008 and joined the faculty at WSU in 2013 after five years in community pharmacy practice. She is the Director of the newly developed Center for Pharmacy Practice Research at WSU and enjoys teaching student pharmacists about patient care and research. Dr. McKeirnan is passionate about research involving community pharmacy, public health, and improving patient access to quality care services. Dr. McKeirnan has received grants for improving immunization rates in rural areas, developing a model for implementing chronic disease-state management services in rural community pharmacies, and developing a pharmacy technician immunization training program.
An Interview with Don Teater, MD, MPH, Founder, Teater Health Solutions
by Kayland Arrington, MPH, Program Manager at NaRCAD
NaRCAD: Can you tell us about your background? How did you become an addiction treatment specialist?
Don: I was trained as a primary care physician, and my wife, Martha, is a behavioral health specialist. The two of us had an integrated-care model, where we did a lot of addiction treatment. I wanted to address that more specifically. An important part of my practice has always been to help those who couldn’t otherwise get help. I did medical work in Honduras, and then I realized that we had a large population of migrant farm workers where I lived in North Carolina. Most of these farm workers didn’t speak English or have a way to receive healthcare. With the help of others, I then opened a free clinic.
As far as addiction, I realized that so many patients initially became addicted from my colleagues and me prescribing opioids. The opioid crisis is a public health issue, and medical school doesn’t train you for public health work. Medical thinking addresses what is going on right now, but public health is so much bigger than that. I decided to get a master of public health degree at the University of North Carolina, and I completed that in 2017.
NaRCAD: How does Academic Detailing lend itself to the opioid crisis?
Don: Academic detailing can help by having more people with lived-experience do the detailing. In Wisconsin, people with lived experience are either going out with a detailer as a team or doing the detailing themselves. There is also a shortage of people treating OUD. AD is a great program for sharing how to get waiver trained to prescribe buprenorphine for OUD. AD lends itself well to the opioid crisis because it’s an area where little changes can make a big impact.
NaRCAD: There is a huge problem with stigma when it comes to opioid use disorder (OUD), as with any substance use disorder. How can we combat stigma?
Don: I hear a lot from other clinicians that they don’t want “those people in my waiting room.” They are picturing someone who is all strung out on heroin on the street corner. We don’t get any education on addiction in medical school and the whole concept is overwhelming to clinicians. The best way to overcome stigma is for clinicians to have interactions with more people with OUD. I think that can be done by clinicians prescribing buprenorphine. I had to deal with my own stigma. For example, I had patients on opioids for chronic pain. I then found out they got arrested or were getting drugs from somewhere else, and I would just fire them from my practice. I saw them as bad people. Once I got trained to prescribe buprenorphine, I listened to their stories. I had made the same choices as many of my patients, yet they became addicted because of their personal history, social history, and genetics.
There’s also the importance of language. A lot of the older language around OUD identifies with bad choices and bad people. For example, relapse is associated with a fault of the person. When we are talking about a person with OUD, we are talking about someone with a disease and relapse is a natural course of the disease. When a patient’s blood sugar goes up, we don’t call it a relapse. Just like people with diabetes, we will never cure a person with OUD, but we help them manage.
NaRCAD: We have heard from detailers that many clinicians ask "isn't medication-assisted treatment (MAT) just trading one drug for another?" What do you say to that?
Don: There is so much data that shows the first and best treatment for OUD is MAT. There are 11 criteria for OUD, and they are all behavioral. Once people get on the medication, they meet zero of the criteria for OUD. We don’t have many medications for other diseases that can do that. France had a big problem with heroin, and by making buprenorphine more readily available, overdose rates dropped by 80% in 2 years.
NaRCAD: Based on all your research and knowledge, what can be done to stop the opioid crisis?
Don: We need to prescribe fewer opioids. A lot of our medical education is still driven by pharmaceutical companies. AD can help by disseminating the evidence on the appropriate treatment of pain. It was only in 2016 that the CDC first came out with guidelines saying opioids should not be the first line of treatment for people with chronic pain. It typically takes 17 years for research to become routine care, and there has already been a lot of uptake with this. Next, we should have all clinicians prescribing buprenorphine, like what France did. We also need to change our criminal justice system to reduce penalties for being found with a controlled substance, including heroin. I am optimistic about each of these things, and think they are all likely to be done in our lifetime – hopefully in the near future.
Don Teater, MD, MPH
Teater Health Solutions
Don Teater is a family physician who has lived and worked in western North Carolina since 1988. His work in the southern Appalachian Mountains made him aware of the problems with opioid pain medications years ago. In 2004 he started a clinic to treat those addicted to opioids in his primary care practice. From 2013 to mid-2016, he worked as Medical Advisor at the National Safety Council addressing the national epidemic of opioid abuse, addiction, and overdose. Dr. Teater was lead facilitator for the expert panel discussion during the development of the CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. Dr. Teater has also served on the World Health Organization Committee addressing drugged driving that met in Mallorca Spain in December 2015. Since June 2016, Teater has worked for Teater Health Solutions to concentrate on educating prescribers and others on the science of opioids and how that should influence treatment and policy decisions. Currently he contracts with the Center for Disease Control on the academic detailing of prescribers to educate them on the appropriate use of opioids for the treatment of pain.He continues to work one day per week treating those afflicted by the disease of addiction at Meridian Behavioral Health Services in western North Carolina.
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.
An Interview with Victoria Adewumi, MA, Community Liason, City of Manchester Health Department
NaRCAD Training Alumna
by Kayland Arrington, MPH, Program Manager at NaRCAD
NaRCAD: How did you get into AD? How was the Manchester team formed?
Victoria: I was very interested in community outreach and improving the health and well-being of families! I had cursory experience with substance use disorder management and had to jump in with both feet. It really helped having other detailers on the team that NaRCAD trained that I could lean on. The other detailers constantly provided support, and one helped open the door for me at her health system to speak with clinicians. She even provided me talking points that previously worked for her so I could walk into my first appointment feeling confident.
NaRCAD: What has your experience been as a detailer who does not have clinical experience but who does have public health expertise? Is someone able to be effective as an academic detailer without as much prior clinical training?
Victoria: My experience has been extremely positive! I care about community, and I thought this was a great opportunity to gain new expertise in this field. I’ve always felt that a community perspective is needed for us to be able to leverage our impact in this field.
The NaRCAD Academic Detailing techniques training was fantastic in helping me build tools to be able to speak well and motivate clinicians around medication-assisted treatment (MAT). My goal as an individual detailer is always to present myself as being on the same team as clinicians. I really see detailing as having a solution for clinicians, rather than simply trying to sell them an idea.
NaRCAD: Was there a time when a clinician presented pushback or obstacles that made it difficult to get your message across?
Victoria: Some clinicians seemed to have already decided whether they were going to be on board or not before I even met with them. I had to feel strong and confident in the skills that I have. When I meet with a clinician, I always frame it as “I’m coming in as a representative of the community. There’s a crisis in our community, and you, as a provider, are a key part of the solution. How can we get you involved?” and “What kinds of things can you tell us that we haven’t even thought about before?” We need everyone’s participation if we’re going to change the tide of the city of Manchester, and clinicians are a vital part of that.
NaRCAD: You have mentioned the power of the team of detailers--can you tell us how the Manchester AD came to be so strong and effective?
Victoria: I didn’t know any of the other detailers before the project. The NaRCAD training was great as an introduction to the work and to each other. We all had a sense of hope that was immediately apparent. We have the privilege of doing work that helps save lives and because of this attitude, there was a sense of camaraderie right away. We’ve been effective because our AD team is strong, and it was strong because we were intentional about building bonds. During the implementation period, we never went more than a month without checking in with each other, and sharing successes and challenges.
I don’t think I would have enjoyed the process as much if I didn’t have this amazing AD team of colleagues. We’ve had incredible success in building a team of detailers who are all committed to and excited about the work of connecting with frontline clinicians to improve patient care around opioid safety.
NaRCAD: How would you recommend other programs go about recruiting those people that are equally committed and excited?
Victoria: That’s a great question! I didn’t necessarily have an opioid response background, but I’ve always cared about communities. That desire to help others makes a great detailer. The trainings can teach the clinical content, but that element of wanting to improve people’s lives is the anchor of a strong AD team, and will resonate with the providers you’ll be detailing. I would then advise new sites to do the important work of helping their detailers to build strong relationships and a sense of teamwork right from the beginning. Those relationships will support everything, from good communication with clinicians, to a renewed sense of purpose in doing the work, which shields against burn out moving forward. Consistent opportunities to check in and connect between AD team members can’t be overemphasized—it truly made me feel that I was never in this alone; I was always working as part of something bigger than myself.
Victoria Adewumi, MA
City of Manchester Health Department
Victoria Adewumi is a Community Liaison with the Manchester Public Health Department. Victoria primarily helps coordinate and staff programming of the Manchester Community School Project, a model that facilitates better health for Manchester residents through place-based interventions. Victoria serves Manchester residents by linking them to partners in the health, social service, business, non-profit, and faith communities and by engaging community members in resident leadership and equity activities. Victoria also participates in efforts to serve refugees and newcomers in New Hampshire through both direct service and community-building initiatives. Victoria holds Bachelor and Master of Arts Degrees in Political Science from the University of New Hampshire.
Featuring: Mary Nagy, MPH, RN/BSN, Public Health Detailer, HIV Care & Prevention Unit, Michigan Department of Health and Human Services, NaRCAD Training Alumnus
NaRCAD: Thanks for joining us, Mary! You’re a Public Health Detailer in the HIV Care & Prevention Unit at the Michigan Department of Health & Human Services. Before we talk about how you got into your current role, can you tell us what you were doing before that?
Mary Nagy: I was an ER nurse for five years. During that time I worked all over the country in lots of different settings, but I noticed the same patterns playing out no matter what city I was in. I was seeing patients daily who were either in the last hours of their lives or needing immediate life-saving interventions as a result of medical problems that might have been avoided entirely through basic services or preventative medicine. The longer I worked ER, the more clearly I saw the effect of systemic forces and environment on health, their unequal distribution across society, and the more I wanted to find a way to work towards health equity.
I decided to study public health, and earned my master’s degree in Environmental Health Science at the University of Michigan. In addition to giving me the opportunity to design and carry out my own research, the program I did had a strong health policy component, which helped me add to the understanding of healthcare delivery I formed during the time I spent at the bedside.
NaRCAD: Tell us what interested you about your current position and what a “day in the life” of a detailer looks like for you.
Mary Nagy: I saw the job posted and was immediately interested in it because I think detailing, especially on the topic of pre-exposure prophylaxis (PrEP), is a really effective way to strengthen prevention infrastructure and affect health outcomes. Clinicians are under a lot of pressure and I was drawn to the idea of being a source of relevant, high quality, trusted information.
The detailing program here in Michigan is comparatively young and its development is ongoing. Fortunately for me, lots of folks have been willing to help! I've drawn from a broad range of sources has been really helpful during detailing visits, because the needs of providers are so diverse; folks are asking about billing and coding for PrEP visits, standing orders, HIV risk assessment, nuts and bolts of services offered by our state lab, STI screening and trends, and financial supports for PrEP, best practices with PrEP initiation and follow up, and more. I’ve been working hard to broaden my knowledge base, but also to identify resources for questions I don’t know the answers to and topics I’m weaker on.
NaRCAD: Why are you passionate about HIV prevention, and why is academic detailing for HIV prevention so important?
Mary Nagy: Even though I’m very new to the field, I think it’s a very exciting time to be doing this work because I do believe it is possible to end the HIV epidemic in the US within the next few decades. Racial and ethnic minorities continue to be underrepresented in PrEP utilization and overrepresented in new HIV diagnoses, and I want my work to contribute to correcting this. I think PrEP can be a tool for health justice and being part of that is valuable to me.
NaRCAD: You’ve mentioned environment a couple of times. Can you tell us how environment is connected to HIV contraction and prevention, if at all?
Mary Nagy: I think that’s where my mind goes, because I’ve seen the powerful effect of environment on health, and this is certainly true on a population level. I never want to diminish the power and agency of individuals, but everyone operates under multiple layers of forces. Examples of this include policy, especially the persistent legacy of overtly racist housing policies; the “war on drugs” and resulting mass incarceration; or a justice system that data shows us doesn’t work in the same ways for everyone.
These systemic forces, applied to millions of people over many decades, result in the disparities we see in HIV rates, overall health, wealth, and many other areas. Increasing access to PrEP means we can mitigate some risk for folks who might have more exposure due to the environmental context in which they live.
For Michigan, one of the ways detailing can help make PrEP easier to access is increasing geographic availability. A large portion of our state is rural, and many counties do not currently have a known PrEP provider. Another challenge is, of course, cost. The cost of PrEP and associated visits and screening tests is a policy issue, and while we hope and expect to see cost come down in the future, in the current landscape, it's important to prioritize educating providers and their staff on available financial supports and how to apply them, so cost doesn’t keep people who can benefit from PrEP from getting and maintaining access.
NaRCAD: In addition to geography and coverage, what are some other barriers you’ve encountered when doing academic detailing for HIV prevention?
Mary Nagy: Stigma around HIV and other STIs is a big issue. We know that when providers talk openly with patients about their sexual health, they’re better able to accurately assess risk for HIV and STIs and screen and treat appropriately, but those conversations are not happening with enough regularity. Rates of STIs like gonorrhea, chlamydia, and syphilis have been rising, and continue to increase, so there's a lot of opportunity there.
NaRCAD: How has detailing been received overall? Are providers open to education on PrEP?
When I think about why detailing is important and why I’m doing it, the first thing that comes to mind is a recent survey of primary care providers MDHHS carried out in Southeast Michigan. Providers were asked which supports would best help them to incorporate PrEP into their practice, and "education" was by far the most frequent answer. In addition to the research I’ve seen indicating detailing is an effective intervention to change provider behavior, it's clear that the providers themselves agree that education is important. If we can work with providers to make PrEP available and easy to initiate and maintain, the protection it offers from HIV can improve health outcomes for patients at high risk.
Mary Nagy, MPH, RN/BSN
Public Health Detailer, HIV Care & Prevention Unit
Michigan Department of Health and Human Services
Mary is the public health detailer for the State of Michigan and conducts direct outreach with medical providers to support HIV prevention strategies and stigma reduction statewide. She received her master’s degree in Environmental Health Science from the University of Michigan School of Public Health where as a Graham Sustainability Fellow her research focused on municipal water quality and affordability. Mary also has several years of experience working in as an Emergency Department RN in trauma centers across the US and her work in health equity is informed by her time as a frontline health worker.
Highlighting Best Practices
We highlight what's working in clinical education through interviews, features, event recaps, and guest blogs, offering clinical educators the chance to share successes and lessons learned from around the country & beyond.