Beyond Didactic Presentations in Clinical Training: Thinking Outside the PowerPoint Box March 11, 2008 Presented by the National Network of Prevention Training Centers (NNPTC) Parts I (Clinical), II (Behavioral) and III (Partner Services) Featuring … Kees Rietmeijer, MD, PhD Laura Bachmann, MD, MPH Linda Creegan, MS, FNP M. Terry Hogan, MPH Katherine Hsu, MD, MPH Patricia Jennings, DrPH, PA-C Patricia Coury-Doniger, NP, MSN Anne Rompalo, MD, ScM

NNPTC: Who We are Network of 18 regional training centers funded by CDC Each PTC is created as a partnership with a health department and a university Focus on translating research to practice Address STD/HIV clinical, behavioral and partner services training/TA needs

Training Center Locations and Quadrants

Clinical Training (Part 1 PTCs) 10 PTCs each cover one HHS region Focus of training: Enhance clinical skills Learn state-of-the-art STD diagnostics Explore recent advances in STD treatment and prevention STD/HIV interaction issues, including diagnosis, treatment, and management of co-infection Between , delivered > 23,500 hours of clinical training to more than 70,600 STD/HIV medical providers

Behavioral Training (Part 2 PTCs) 4 PTCs each cover a quadrant Focus of Training: Delivery of evidence-based STD/HIV behavioral interventions (i.e. DEBIs) Increase capacity to support behavior change for STD/HIV risk reduction Improve STD/HIV prevention practices in the community

Partner Services Training (Part 3 PTCs) 4 PTCs each cover a quadrant Focus of Training: Effective STD/HIV interviewing/counseling skills Develop critical thinking skills to support STD case management Enhance program capacity to address emerging disease trends

Didactic Training Focus on knowledge transfer Mostly unidirectional Variety of delivery modalities: –In person: individual, small and large groups –Printed materials –Online Types: –Lectures, Slides, Videos –Readings –Demonstrations

Experiential Training Focus on skills building Mostly bi-directional: –“Show one – do one (teach one)” Delivery modalities: –In person, one on one, small groups Hands-on with patient Precepting –Online: interactive

Experiential Training Examples –Intensive Courses (3–5 days) –Lab Courses –Interactive web-based courses

Examination Skills Courses Laura H. Bachmann, MD, MPH Medical Director Alabama/North Carolina STD/HIV PTC

Taking an STD/HIV History Learn which questions to ask and how to ask them!

Taking a Sexual History Learn how to transition to progressively more sensitive topics more comfortably Practice makes perfect! –Role playing –Videotaping Feedback provided!

Completing a STD/HIV Behavioral Risk Assessment Role playing interviewing techniques Videotaping of risk assessment techniques with feedback

An array of skills-based courses available… Venipuncture Techniques Models Clinical practice Preceptor mentoring

STD Exam Skills Pelvic trainers Surrogate models Clinical practicums –For the novice –For the more experienced Preceptor mentoring

STD Specimen Collection Skills Techniques Pelvic trainers Surrogate models Clinical practicums Preceptor mentoring

Clinical Laboratory Skills STD rapid laboratory tests: –Rapid Results to guide clinical decision making –HIV rapid laboratory tests

Laboratory Procedure Courses Linda Creegan, MS, FNP California STD/HIV PTC

CLINICIANS….. Are you new to the STD clinic? Is your clinic starting to use a new test? Herpes? Trichomoniasis? Bacterial Vaginosis? Rapid HIV test? Syphilis? Darkfield microscopy?

NNPTC Laboratory Procedure Courses Participants learn to perform..... Tests for STD specialty clinics –Syphilis tests Rapid RPR test Darkfield microscopy –Gram stains –Saline and KOH wet mounts Other Point-of-Care (POC) tests for STD and HIV

Tests for STD Specialty Clinics

Serologic Tests for Syphilis Utility of rapid RPR test –Evaluate patients with symptoms of primary or secondary syphilis –Assess contacts to syphilis infection –Facilitate immediate diagnosis, treatment, and initiation of partner management activities Learn to perform and interpret qualitative and quantitated RPR tests

Darkfield Microscopy Evaluate patients with ulcers typical of primary syphilis Learn to –Obtain the specimen –Use the darkfield microscope –Identify T. pallidum by morphology and motility Photo credit: Dr. Joseph Engelman, San Francisco City Clinic

Identifying T. pallidum by DF Morphology –Rigid, uniform, tightly- coiled spirals –Length: 6-20 micrometers –Width: VERY thin micrometers, below the resolution of the light microscope Motility –Exhibits three types of movement Translation: slow, forward or backwards movement Rotation: turning around the longitudinal axis Flexion: stiff bending, usually in the middle, and returning to original position

Gram Stains Evaluate male urethral specimens Learn to –Obtain the specimen –Identify polymorphonuclear leukocytes (PMNs) and Gram-negative intracellular diplococci (GNID) –Diagnose gonococcal vs non-gonococcal urethritis STD Atlas, 1997

Saline and KOH Wet Mounts Vaginal Specimens Differentiate the causes of vaginal discharge Learn to –Obtain the specimen –Use the light microscope –Identify findings (clue cells, yeast forms, trichomonads) –Diagnose bacterial vaginosis, yeast, trichomoniasis Photo credit: Seattle STD/HIV Prevention Training Center

Other Rapid Point-of-Care Tests for STD

What are Point-of-Care tests? Run in clinic or field setting Provide results at same clinic visit Very easy to perform –Usually require only microscope or simple lab equipment –Often CLIA waived

Point-of-Care STD Tests: A Paradox Generally not as sensitive/specific as delayed lab tests –Not intended to replace traditional STD tests, where these are available HOWEVER… In populations of patients less likely to return for results or when F/U is difficult, higher treatment levels can be achieved with POC than with delayed tests –Homeless clinics –Emergency rooms –Correctional facilities

Point-of-Care STD Tests POC tests for common STD –HSV 2 –Bacterial vaginosis –Trichomoniasis –Chlamydia –Gonorrhea Learn about –Lab regulatory issues (CLIA) –Obtaining specimens –Using test kits –Interpreting results –Maintaining quality assurance

Rapid HIV Tests Learn about….. Performing oral fluid and fingerstick tests Giving positive and negative test results

Enroll in a Lab Procedure Course offered by your regional Prevention Training Center!

Interactive Approaches to Learning M. Terry Hogan, MPH Region III STD/HIV PTC, Maryland

Considerations for Rural Nurses –Standing Orders –Comprehensive Exam Skills –Specimen Collection –Partner Services Referrals –On Site Training –Skills for Sexual History Taking –Skills for Symptom Observation –Skills for Risk Reduction Counseling Interactive Approaches to Learning

Considerations for Virtual Clinic Experience –Registration –Clinic Flow –Clinic Staffing –Laboratory Capability/Support –Examination Room –Medical Records –Counseling Room –Data Collection and Surveillance

Interactive Approaches to Learning Kees Rietmeijer, MD, PhD Region VIII STD/HIV PTC, Denver

Discussion of Challenging Cases Example: small group sessions during annual Denver STD Update –15-20 participants –Case studies: NGU PID Genital Herpes Syphilis –Discussions in small groups moderated clinicians from Denver STD Clinic

Precepting in Regional Model Clinics Example: Intensive Course (3–5 days) –Didactic Sessions (50%) Clinical Exam Lab Methods STI Overview: Clinical, Diagnostic, Therapeutic Counseling –Experiential Learning (50%) Clinical precepting Hands-on with patient Skills demonstration and practice

Interactive Web-based Courses on STD Case Management Katherine Hsu, MD, MPH Sylvie Ratelle STD/HIV PTC of New England

Why Is Internet-Based CME Attractive? Improved access –Flexibility in time and place Greater adaptability to learner style Potential to be more interactive –Realistic problem-solving –Performing tasks in context of clinical problems –Linkage to other resources –Participation in social dialogue These approaches in line with adult learning theories

Objective: To determine if Internet-based CME produced changes comparable to changes via live, small- group, interactive CME Design, Setting, Participants: Randomized controlled trial August 2001 – July primary care physicians in Houston Interventions: Randomized to Internet-based CME intervention completed over 2 weeks OR Single, live, small-group, interactive CME workshop Both with multifaceted instructional approaches Content based on NIH National Cholesterol Education Program Main Outcome Measures: Knowledge: pre-intervention, immediately post, 12 wks later Chart audits: 5 mths pre and post-intervention chol. screening, med use rates Results: Similar knowledge gains Similar high baseline screening rates, non-sig. post-intervention changes Internet-based intervention associated w/ sig. increase in % of hi-risk patients treated with meds according to guidelines Conclusions: Appropriately designed, evidence-based online CME can produce objectively measured changes in behavior as well as sustained gains in knowledge that are comparable or superior to those realized from effective live activities

Concluding Remarks and Transition Linda Creegan, MS, FNP California STD/HIV PTC

Experiential learning for a holistic approach to our patients with STD NNPTC Trainings prepare you for all aspects of STD patient care –Taking a Sexual history –Physical exam –Laboratory testing –Diagnosis and treatment –Partner management –Risk reduction counseling

Here’s what to do now….. Choose 2 skills-building stations –Room: Williford C : Syphilis case discussion and RPR demonstration –Room PDR 5 : Effective risk reduction counseling –Room PDR 6 : Male and female pelvic exam skills –Room PDR 7 : Taking a sexual history Move to first breakout station 3:45-3:50 –First station:3:50-4:15 Switch!! 4:15-4:20 –Second station: 4:20-4:45

Syphilis Case Study Patricia R. Jennings, DrPH, PA-C Alabama/North Carolina STD/HIV PTC

History Stan Carter is a 19-year-old male who presents to the STD clinic Chief complaint: penile lesion x 1 week Last sexual exposure was 3 weeks prior, without a condom No history of recent travel 3 female partners in the last 6 months and 2 male partners in the past year Last HIV antibody test (2 months prior) was negative Case Study

Physical Exam No oral, perianal, or extra-genital lesions Genital exam: Lesion on the ventral side near/at the frenulum. Lesion is red, indurated, clean- based, and non-tender. Two enlarged tender right inguinal nodes, 1.5 cm x 1 cm Scrotal contents without masses or tenderness No urethral discharge No rashes on torso, palms, or soles. No alopecia. Neurologic exam WNL. Case Study

Questions 1.What are the possible etiologic agents that should be considered in the differential diagnosis? Case Study

Herpes Simplex Virus Herpes Simplex Virus (HSV): most common cause of genital ulcer disease in the US

Chancroid Haemophilus ducreyi: rarely seen in the US; characterized by painful lesions with irregular borders

Lymphogranuloma venereum Lymphogranuloma venereum (LGV): rare in the US; causes a relatively painless and superficial ulcer Groove Sign

Syphilis Treponema pallidum (syphilis): well- circumscribed indurated ulcer with a clean base and regional lymphadenopathy

What is the most likely diagnosis?

Which laboratory tests would be appropriate to order or perform? A stat RPR Darkfield microscopy Nontreponemal serologic test (RPR, VDRL) Treponemal serologic test (FTA-ABS, TPPA) should accompany a nontreponemal test because the use of only one type of serologic test is insufficient for the diagnosis.

Sensitivity of Serological Tests in Untreated Syphilis Stage of Disease (Percent Positive [Range]) TestPrimarySecondaryLatentTertiary VDRL78 (74-87)10095 (88-100)71 (37-94) RPR86 (77-99)10098 (95-100)73 FTA-ABS*84 (70-100) Treponemal Agglutination* 76 (69-90)10097 (97-100)94 EIA93100 *FTA-ABS and TP-PA are generally considered equally sensitive in the primary stage of disease. Diagnosis

Which laboratory tests would be appropriate to order or perform? HSV test: culture, antigen detection tests for HSV as available. HSV serologic testing an option HIV testing Gonorrhea and chlamydial testing at site of exposure

Stat Lab Results The results of stat laboratory tests were as follows: –RPR: Nonreactive –Darkfield examination: Positive for T. pallidum Case Study

What is the diagnosis? Primary syphilis: The identification of T. pallidum on darkfield examination confirms the diagnosis. A positive RPR is not required for the diagnosis. Serologic tests for syphilis, such as RPR, may be nonreactive, particularly in early primary syphilis.

What is the appropriate treatment? The appropriate treatment for primary syphilis in an adult is Benzathine penicillin G 2.4 million units IM in a single dose Threshold for initiating therapy should be LOW!!!

Reference Lab Results RPR: Nonreactive FTA-ABS: Reactive HSV culture: Negative Gonorrhea culture: Negative Chlamydia DNA-probe: Negative HIV antibody test: Negative Do the reference laboratory results change the diagnosis? NO Case Study

Stan’s Sex Partners Tracy – last exposure 3 weeks ago Danielle – last exposure 6 weeks ago Jonathan – last exposure 1 month ago Tony – last exposure 8 months ago Carrie – last exposure 6 months ago Which of Stan’s partners should be evaluated and treated prophylactically, even if their test results are negative? Case Study

Tracy, Danielle and Jonathan Partners exposed within 90 days prior to the onset of symptoms may be infected even if seronegative. Therefore, they should be treated presumptively. Partners exposed to patients with primary syphilis more than 90 days prior to the onset of symptoms are unlikely to be related to the infection. (Partners > 3 months, test then treat)

Demonstration of RPR