1. Depression as Chronic Disease: A Curriculum for a Family Medicine Clerkship David L Gaspar MD, Wendy Madigosky MD MSPH, Bonnie Jortberg MS RD CDE, Deb Seymour PsyD, Cindy Villanueva MS Dept. of Family Medicine University of Colorado

2. The Room Who are you? Who teaches Depression/Chronic Disease Management? Who coordinates clerkships? Any preceptors? What do you hope to learn?

3. Lecture-Discussion Objectives Discuss the state of Chronic Disease Management education (5min) Describe the elements of our curriculum development process Explain the methods used to teach Chronic Disease Management to medical students using depression as a model. (10min)

4. Lecture-Discussion Objectives Describe the impact on the learners and the clerkship site and their instructors. (15min) Discuss and share experiences from their programs and offer suggestions for improved instruction in managing depression and other chronic diseases. (15min)

5. Why is it important for Family Medicine to be teaching this? Increasing need for chronic disease management with aging population –Almost half of all Americans live with a chronic condition (133 million) –Increase is 1% per year Decreasing primary care specialists Role for FM and therefore for teaching chronic disease management within FM clerkship

6. State of Chronic Disease Medical Education Who is teaching it? What are they teaching? When? How?

7. Who? What? When? How? UME –Longitudinal home visits in 1 st and 2 nd year –Elective 3 rd year week-long course –Chronic Care Selective 4 th year –4 th year Australian Med Students

8. Who? What? When? How? GME –AAMC Chronic Care Collaborative Institute for Improving Clinical Care Ed Wagner’s Chronic Care Model 22 institutions participating

9. Informed Activated Patient Productive Interactions Prepared Proactive Practice Team Functional and Clinical Outcomes Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Resources & Policies Community Health Care Organization Chronic Care Model

10. Who? What? When? How? Inter-professional teaching –UCSF IM residents, NP and pharmacy students

11. How is it being evaluated? Satisfaction Reflection Pre/Post Knowledge and Attitudes

12. Overarching Goals Development Introduce chronic disease management (process of care) into a clerkship Enhance instruction on depression Introduce guideline use and decision rules to our students Encourage local guideline use by preceptors

13. Context 6 week FM clerkship– mainly rural, Depression is a “top ten” condition –Orientation on the first morning of clerkship –Use online Discussion Groups –PowerPoint project at conclusion of the clerkship –Evaluation includes SP cases No instruction on Chronic Disease Management in our SOM curriculum

14. Context Colorado Clinical Guidelines Collaborative (CCGC) produces local guidelines and associated materials. Preceptor awareness? Suboptimal treatment of depression in primary care has been described Problems with access to mental health resources common in rural Colorado

15. Development Group FM Predoc Group, DFM behavioral science and pharmacy faculty Pilot spring of 2005. Orientation: pharmacotherapy, tape/role play on asking about depression, suicide facts, screening for bipolar disease, differences in presentation between psych and primary care

16. Development Pilot spring of 2005. Task: Students to use screening tools and other materials, examine how the practice is set up to manage depression, investigate community mental health resources (algorithms, flow sheets etc.) then report back by way of a PowerPoint presentation.

17. Development-Results Students perceived “Too much” emphasis on Depression Wanted info on managing other chronic diseases Role plays/tapes not focused enough Students didn’t always use the tools as we asked them to do

18. Current curriculum FIVE Components: Orientation Using depression screens and flow sheets for management “Cueing” through online discussion groups PowerPoint presentation at the end of the clerkship SP case of Daniel Allen a college student with insomnia

19. Current Curriculum- Orientation Generally same format. Introduced orientation with a case Use multiple analogies with other chronic diseases i.e. asthma Stress on reevaluating disease and adjustment of therapy

20. The Chronic Care Process Self-Management Decision Support Delivery System Design Clinical Information SystemClinical Information System Organization of Health Care Community Alliances

21. Current Curriculum - Materials used Colorado Clinical Guidelines Collaborative – published materials on asthma, diabetes mellitus, depression, colorectal cancer screening, smoking cessation and appropriate antibiotic use.

22. Current Curriculum- Cueing to use Materials Blackboard discussion group

23. Evaluation Determine effectiveness of depression care curriculum for both students and preceptors –For preceptors, determine how our curriculum matches with preceptor’s care in the community Assess knowledge about “process of care” –Is depression being treated as a chronic illness? Determine both student and preceptor perspective on impact of depression care curriculum on preceptor’s practice

24. Survey Methods On-line survey (Zoomerang) Pre-and-post clerkship survey Students: Pre-survey N = 46 Post-survey N = 32 Preceptors: Pre-survey N = 38 Post-survey N = 18 Results have not been analyzed for statistical significance

25. Types of Survey Questions Demographics (gender, preceptors - # of years in practice, rural, urban or suburban practice) General knowledge and attitudes about depression care Preceptors: barriers to mental health care in their communities Use of Colorado Clinical Guidelines and treatment of depression as a chronic disease Impact of depression curriculum on preceptor’s practice

26. Results Overview (Students) 46% male; 54% Female Suicide rate in Colorado compared with U.S.: –Pre: 28% high; 50% same; 22% low –Post: 97% high; 3% same When would you formally reassess a patient who has achieved remission? –Pre: 56% Every 2-3 months –Post: 78% Every 2-3 months Observed preceptor (or Foundations or other clinical rotation preceptor) who utilizes CO Clinical Guidelines for depression: –Pre: 7% Yes, 93% No –Post: 38% Yes; 63% No

27. Times Used Depression Screening Tools (Students) 37% 56%

28. How often have your seen your preceptor (or attending physician) treat depression as a chronic disease?

29. Results Overview (Preceptors) 61% male; 39% Female Number of Years in Practice: –21% 0-5 years –21% 6-10 years –58% > 10 years 83% in rural practice; 17% in urban/suburban practice

30. Results Overview (Preceptors) 82% felt access to MH resources were inadequate –Majority (78%) said MH resources inadequate because of lack of MH professionals in community and expense of MH professional not covered by insurance or not affordable for patient 97% reported feeling comfortable assessing & managing depression in their practice 92% found treating patients with depression to be rewarding

31. Results Overview (Preceptors) Suicide rate in Colorado (Pre-clerkship): –47% high –53% similar –0% low Pre-survey, 39% reported either “never” or “rarely” using a depression screening tool Post-survey, 24% preceptors said having a student use depression screening tools during the Clerkship made them more likely to use these tools in their practice

32. How Likely are you to Utilize the Colorado Clinical Care Guidelines for Depression? (Preceptors)

33. Which of the following were important to learn during the clerkship?

34. What do you think the effect of conducting the depression screening tasks had on your preceptor’s practice? (Check all that apply)

35. Challenges Use this model for other Chronic Diseases or other care issues How to add within orientation time constraints

36. Faculty development We can do more Initially only an introduction to our student “depression assignment” Use online surveys and used results for preceptor feedback To some extent are using the curriculum itself for faculty development

37. Conclusions-What We Learned FM clerkship can be a good setting to introduce students to “process of care” Educational tasks given to students may provide an avenue to increase guideline use in preceptor offices Preceptors perceived student tasks as providing some added value (even though students did not necessarily)

38. QUESTIONS