Beyond opioid prescribing: Evaluation of a substance use disorder curriculum for OBGYN residents

Caitlin E. Martin; Bhushan Thakkar; Lauren Cox; Elisabeth Johnson; Hendrée E. Jones; AnnaMarie Connolly

doi:10.1371/journal.pone.0274563

Peer Review History

Original SubmissionJune 2, 2022
12 Aug 2022 Decision Letter - Nadine Harker, Editor Transfer Alert This paper was transferred from another journal. As a result, its full editorial history (including decision letters, peer reviews and author responses) may not be present. PONE-D-22-16004Beyond Opioid Prescribing: Evaluation of a Substance Use Disorder Curriculum for OBGYN ResidentsPLOS ONE Dear Dr. Martin, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Sep 26 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. 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Reviewer #1: Yes ******** 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: Abstract- some acronyms not explained and difficult to understand. Suggest removing those not explained if word count is an issue. (ACGME) Ethical statement- What does IRB stand for? Introduction- Line 1- overdose crisis- opioid overdose or general overdose of all illicit substances? Line 90- Non American readers will not know what ACGME is. Please provide a brief description/explanation of who they are and what they do. Table 1: there is an * that explains ACGME but no corresponding . this explanation should be earlier in text. Methods Line 138 notes 6 residents that were due to participate. Later in line 186 there are 4 interviews that take place. Cant follow any explanation of what happened to the other 2 and why not all participated. Table 2 - the scale needs clarity. The scale is 1-4 but there are 5 descriptors (show how and Tell, Active Help, Passive Help, Supervision Only, Expert) Results Line 209- all 18 residents. This is confusing as initially there were 6, then 4 interviews and now 18 completed the curriculum. A better explanation of the numbers is needed. Table 3 could be better interpreted after table 2 is clarified. It is clear there is an improvement in the PGs supervision needed but at what level and how do the scores correspond to the categories? Line 221- what was the purpose of the extended curriculum? Who was it offered to and why was it not part of the original curriculum that was being studied? Discussion There is some room for discussion around stigma and advocacy for patients with SUD. Some discussion around the concept of harm reduction would also be helpful as not all people are in the same stages of change (even with motivational interviewing) and preventing negative consequences of drug use should be seen as key to preventing esp infectious diseases like HIV and hepatitis. General- Good topic. i think its very important for specialists to be able to identify and manage SUDs. The methods section and participant numbers and enrolment needs more clarity. ******* 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. 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Revision 1
19 Aug 2022 Author Response Journal Comments Please provide additional details regarding participant consent. In the ethics statement in the Methods and online submission information, please ensure that you have specified what type you obtained (for instance, written or verbal, and if verbal, how it was documented and witnessed). If your study included minors, state whether you obtained consent from parents or guardians. If the need for consent was waived by the ethics committee, please include this information. Thank you for your comments. We have included the consent details in Lines 104-105 and on the submission website. Reviewer Comments to the Author Reviewer #1: Abstract- some acronyms not explained and difficult to understand. Suggest removing those not explained if word count is an issue. (ACGME) Ethical statement- What does IRB stand for? Our apologies for not explaining the acronyms. We have made the necessary changes throughout the manuscript. For example, in the abstract we have spelled out ACGME to “Accreditation Council for Graduate Medical Education Milestones.” Introduction- Line 1- overdose crisis- opioid overdose or general overdose of all illicit substances? In line with the shift in drug use and overdose trends, we use the terminology “overdose crisis” as it refers to the epidemic of overdose deaths occurring due to opioids as well as other substances, such as methamphetamine (https://www.cdc.gov/drugoverdose/prevention/index.html). Our SUD curriculum, while it has a large focus on opioid use disorder, does also address intricacies of other use disorders. Line 90- Non American readers will not know what ACGME is. Please provide a brief description/explanation of who they are and what they do. Table 1: there is an * that explains ACGME but no corresponding . this explanation should be earlier in text. We have added more information about the ACGME and its milestones in lines 89-91 and 170-175. For example, we now state in the introduction: “Thus, the objectives of this study were…to explore its ability to improve attending evaluations of residents’ clinical skills according to the benchmarks set forth by the United States’ guiding body for resident education, the Accreditation Council for Graduate Medical Education Milestones (ACGME)…” We also added a to ACGME in Table 1 to correspond to the footnote for this acronym. Methods Line 138 notes 6 residents that were due to participate. Later in line 186 there are 4 interviews that take place. Cant follow any explanation of what happened to the other 2 and why not all participated. Unfortunately, due to residents being pulled to cover clinical duties on other services at the height of the COVID-19 pandemic for our hospital, 2 residents were not able to complete all curriculum sessions in the academic year of recruitment for the qualitative interview. We have clarified this in the text: “Due to shifting of clinical responsibilities in the COVID-19 pandemic, only four out of the possible six residents completed all 6 sessions of the curriculum. These residents (n=4) also completed both the self-assessments and interviews.” We have included this in lines 142-144. Table 2 - the scale needs clarity. The scale is 1-4 but there are 5 descriptors (show how and Tell, Active Help, Passive Help, Supervision Only, Expert) Thank you for noting this typo. Our apologies for the confusion. The range of scores on the Zwisch Rating Scale is 1-5. We have made the changes in line number 159. Results Line 209- all 18 residents. This is confusing as initially there were 6, then 4 interviews and now 18 completed the curriculum. A better explanation of the numbers is needed. Thank you for your comments. Since our study was conducted across 3 academic years with the COVID-19 pandemic during that timeframe, our sample sizes for our outcomes corresponding to the study aims do differ. Figure 1 gives detail about our study sample. For clarity, for our three outcomes in the results text, we have also added a sentence at the start of every paragraph describing the number of residents who completed that outcome. For our primary objective assessing curriculum effectiveness, 18 PGY-1 OBGYN residents completed the Clinical skills resident self-assessments. This has been included in lines 216-217. For our exploratory aim, where we assessed curriculum effectiveness using myTIP report, evaluations for 10 PGY-1 OBGYN residents were completed by the teacher Attending. This has been included in lines 231-232. For our exploratory aim, where we assessed curriculum feasibility and acceptability using semi-structured resident interviews, 4 PGY-1 OBGYN residents completed the interview. This has been included in line 242. Table 3 could be better interpreted after table 2 is clarified. It is clear there is an improvement in the PGs supervision needed but at what level and how do the scores correspond to the categories? We have added more information explaining the results in lines 219-224: “As an example, for the core clinical skill where residents counseled patients with SUD, residents reported requiring, on average, direct supervision before the curriculum. After completing the curriculum, residents quantitatively reported improvement in this skill, stating they now required no more than indirect supervision. Similar improvements were observed for the other core clinical skills.” Line 221- what was the purpose of the extended curriculum? Who was it offered to and why was it not part of the original curriculum that was being studied? For the academic year 2018-2019, when the pilot curriculum was initiated, the curriculum included 3 outpatient clinical sessions; this was primarily driven by what accommodated the resident schedules and the fact that the OBGYN-Addiction faculty leading the curriculum joined the institution that academic year. During these 3 sessions, residents were expected to demonstrate their knowledge as they saw patients and coordinated plans of care with the OBGYN-Addiction attending. After reviewing the results from the first year and positive feedback from residents, the OBGYN-Addiction faculty added three more sessions to the curriculum, and the residency leadership accommodated resident schedules to complete the extended curriculum in academic year 2019-2020. In these additional sessions, the residents were expected to demonstrate, through their performance, that they are capable of using their knowledge gained during the initial three sessions while being supervised and observed. The 6 session (extended curriculum) continued to be offered to residents during the third academic year of this study, 2020-2021. Discussion There is some room for discussion around stigma and advocacy for patients with SUD. Some discussion around the concept of harm reduction would also be helpful as not all people are in the same stages of change (even with motivational interviewing) and preventing negative consequences of drug use should be seen as key to preventing esp infectious diseases like HIV and hepatitis. We agree; these topics are very important! We have added more discussion about harm reduction with a citation about our clinic to lines 289-293: “Notably, patients seen in the clinical setting of this study vary substantially in their stages of change, as the clinic prioritizes a low-threshold, harm reduction approach; this represented a unique opportunity for residents to apply their new Motivational Interviewing skills and compassionate, person-centered approaches as role modeled by the clinic providers.” We have added more discussion about stigma with citations to lines 311-318: “Additionally, addiction stigma is, arguably, the most significant barrier to accessing and utilizing evidence-based SUD treatments, especially during pregnancy. While not an outcome assessed in this study, stigma was addressed throughout the resident clinical experiences; for example, all residents are required to review addiction person-centered language recommendations and are given immediate feedback on their language in the clinic. Since this study, we have added additional person-centered language training focused on addiction among pregnant and parenting people, with the goal to prepare the next generation of OBGYN providers to be leaders in destigmatizing the disease of addiction.” General- Good topic. i think its very important for specialists to be able to identify and manage SUDs. The methods section and participant numbers and enrolment needs more clarity. Thank you for the feedback; we appreciate it. We believe we have addressed the comments above adequately with additional clarity about our study design and sample to couple Figure 1. Attachments Attachment Submitted filename: Response to comments_RI.docx https://doi.org/10.1371/journal.pone.0274563.r002
31 Aug 2022 Decision Letter - Nadine Harker, Editor Beyond Opioid Prescribing: Evaluation of a Substance Use Disorder Curriculum for OBGYN Residents PONE-D-22-16004R1 Dear Dr. Martin, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Nadine Harker, Ph.D Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0274563.r003
Formally Accepted
6 Sep 2022 Acceptance Letter - Nadine Harker, Editor PONE-D-22-16004R1 Beyond Opioid Prescribing: Evaluation of a Substance Use Disorder Curriculum for OBGYN Residents Dear Dr. Martin: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Prof Nadine Harker Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0274563.r004

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