Yeah, thank you all for being here today. I can appreciate the dwindling energy on a Sunday afternoon. So I'm very happy that you all made it here. I'm really excited to be here as well. I'm Jordan Broadway. I'm a third year resident in the Duke psychiatry program. And I'm joined today by my two very favorite colleagues, the good doctors, Myles Christensen and Brian Lau. And we're gonna be doing a sort of a fun interactive session today. So there may be a little bit of conversation and collaboration. I hope you're all on board with that. And we are going to start with, just to briefly run through our agenda. Brian's gonna walk us through some pros and cons. We're gonna do a simulated patient encounter. We're gonna debrief, do a brief small group activity. We're gonna kind of reflect on the process together. And the hope is that we'll have an opportunity together, collectively, to kind of explore this interface between virtual learning, delivering chalk talks, and how that impacts the patient care that we're delivering and the ways that we interact with patients. And I'm gonna briefly cover our learning objectives. So hopefully at the end of today, we are all going to be able to discuss the pros and cons. I'm typing on a new keyboard over here for the first time, which is always a fun experience, of using chalk talks in a virtual platform as a, oh goodness, patient with an extra letter, decision-making tool, which is what Brian's gonna walk us through. And then hopefully we will all be able to use at least three different tools and or resources that can be implemented in patient care areas. And then finally, what we're gonna do on our small group activity is we are all going to design a chalk talk. This will be your unique chalk talk today that you can use. And we'll talk more about that. And so to kind of kick things off, I'm going to go ahead and use a survey tool. So hopefully you have all used Menti before. Feel free to, you have not. I've heard, I saw a head shake, that's fantastic. Okay, this is a wonderful program that I'm a huge fan of. If you go to, you can go to menti.com and type in this code to participate in the survey tool. You can also scan the QR code if that is preferable and if you're close enough for your camera to pick up on it. And I will display our poll here. And so I kind of want to just know, just to get a lay of the land, how comfortable do you all feel with using virtual platforms or teaching tools in patient care settings? So in some ways, if you're using any sort of teaching content with your patients, or if you're kind of teaching specifically or exclusively in patient care areas, all of the above. It seems like we have a pretty interesting spread right in the middle, so no one has stumbled in here on accident, which is great. And no one also identifies as being a professional in this space, which is awesome. So we have some fun room to play with. So I'm going to skip to our next question. Maybe we have one accidental attendant. I'm going to skip to our next question, and this is a little bit more free form, and it's just to kind of get this conversation started. And so you should be able to submit as many answers as you would like, but feel free to put any kind of phrases, questions, anything that applies to you in how you use media, virtual platforms, technology, surveying websites, anything like that, in patient-centered decision-making. Oh, YouTube videos. Surveys, turning computer around, links, questionnaires. For whoever put YouTube videos, I'm curious what that looks like, if you feel comfortable. Yeah. Yeah, I love that. Do you find yourself putting links to videos in patient after-visit summaries or patient portals? That's fantastic. I love this GoodRx app opportunity. I have definitely turned my monitor around to show folks the GoodRx coupons and stuff, so that's awesome. And then any other thing that folks want to comment on that they have found that they use frequently in patient sessions? Either out loud or on the questionnaire, excuse me. Oh, yeah, absolutely, I'm sorry. Anything else that you find yourself using frequently in your patient encounters? All right, well, I love these already. So we have videos, questionnaires, links, showing websites, surveys, maybe some like learning through videos and the GoodRx app. Just as a curiosity question, do any of you use apps with patients where you'll instruct them to download apps or any other apps that you've used in encounters aside from GoodRx? Yeah, I see some nods. Okay, great. We're not explicitly talking about apps today, but I think it's an interesting area. So I think with this, I think this is a great place to segue over to Brian who's going to walk us through some of the pros and cons of what using some of these resources can look like. Sweet. Thanks, Jordan. So, yeah, again, I'm Brian, one of the fourth year residents. And so what I'm hoping to do now is to talk about and brainstorm what are, you know, some of the experiences you all have had in doing this and what have been some of the benefits and then some of the downsides in trying to do this. Okay, yeah, I'd love to hear from your experiences, you know, what's been helpful when you're using these digital tools in patient care and then what's been some of the difficulties you've encountered? Yeah, it definitely helps to make it a little bit more approachable, kind of a little tool for you all to be engaging with, definitely. Yeah, you can really leverage it in so many ways to make it a lot more bite-sized and so really helps to meet patients where they are. Yeah. Yeah, pictures, animations, they really go a long way. Yeah, definitely. There's just so many different tools and when you are working with a patient in conversation, you know, like how can you help yourselves organize or help patients follow along? So great. Yeah, it definitely goes both ways where sometimes it's really additive and helps us to take notes and to, you know, carry forward and then on the opposite side, you know, some people don't like that, right? They feel like a classroom, is it too didactic-y and then of course the more tools we're using, it can be distracting as well. I see. Is this when you're giving resources to patients that parents don't like it? Interesting. Yeah, it's a great point. Another hand. Yeah, it's a way to communicate with other providers in a way that's like much faster and so rather than having to sit down with everyone and call everyone, it's a little bit faster. Yeah. There's an element of transparency there too that sounds really important for the patient. I'm going to put mine here. Oh, is it? Yeah. From the audience? Yeah. Okay, I'll definitely try to repeat too. Yeah, sorry. I think your hand's been up for a bit. Yeah, so just to make sure that I'm relaying it, so the first one is the survey fatigue, which I've definitely seen with patients and even with myself for sure too. And then of course with the after-visit summary, trying to utilize it to give the instructions to patients and then positioning it in a positive light. Yeah, it's really interesting. I think some of the things I've heard is like transition object or like maximizing placebo and making it super clear for the patients. It's great. Yeah, we kind of fall victim to the algorithm, right? And we have no say. We have no idea where that's going to lead to. Yeah, it's such a difficult thing to balance, which is when we're giving these resources to patients, it's hard to vet everything especially and there's so many things and there of course is a change and when we're giving people physical copies, it's one thing. They might be able to keep it and then the virtual platforms, if someone were to change it, we might not even know. Yeah, these are great points. Any other thoughts? Yeah, I think when we were thinking about this too and I think we had hit a lot of very similar points and I think there was a lot of great additive points as well. One of the things that we were kind of highlighting is that whenever we're doing these like with patients, if it's over Zoom, one is that it's nice to be able to do it remotely. Maybe I'm watching the news too much, but seeing these encounters with providers being harmed, it's always nice to be able to do some things virtually. I think some of the other pieces is that when we're using these virtual platforms, whether we're doing it in person with patients and turning the computer around or if it's over Zoom, we can really use the same resource for both. Some of the other benefits that we've thought about is if we're giving a presentation, if it's on sleep hygiene, we can always preload images or words and it's nice to have that level of organization and then once we've crafted it once, we can continue to use it and then keep pulling it up. The other one is, someone had mentioned animations, trying to increase engagement when we can, images, GIFs, all the things. Another one that we've really been utilizing a lot is trying to screenshot what we have created with the patient and then we can paste that into the after-visit summary and so they have an exact copy of what we've talked about and then really helping them to follow along and reference back to it whenever they need to. And then the other one would be recording presentations if we wanted to create our own content or if we wanted to give it to the resident or whoever it might be. Some of the downsides we had talked about is whenever we're using digital platforms, at least for me, I think I have what I call Zoom ADHD. I just get so distracted, it's so much easier and so whenever I'm doing this, I definitely am changing the way that I'm approaching it. I don't know if that's the same for you all. I definitely type out everything more. I assume that people are going to be distracted and come back and read it. Some other things is whenever we're using novel platforms and so as technology keeps moving, there definitely is an activation energy to learn something new, get used to it, some things cost money, software is expensive, et cetera. Same thing with hardware, if we need to buy tablets, software, et cetera. And then as we saw earlier, the technical barriers, it's hard to plan for, it's hard to have timing for, hard to have contingency plans. In my experience, if your slides aren't changing over quickly, are you going to spend the next seven minutes fixing it or do you just go along? And then lastly, penmanship can be much harder when we're not on a white board with a marker. When you're using a mouse, my handwriting is already not the best. Add a mouse to that and it gets a little questionable. So yeah, appreciate the discussion. And now I'll move back to Miles and we're going to do a simulated patient encounter. Hey, y'all. I am going to demonstrate a little bit different of a format. We've kind of gone through pros and cons, which has a little bit harder CBT. This comes more from the palliative care literature, which is best case, most likely case, worst case. And so for this patient encounter, the vignette would be a 37-year-old male, history of severe opioid use disorder presenting to your office, history of multiple failed attempts to cease using opioids. He's currently contemplating ceasing opioids with Narcotics Anonymous. He would like to discuss medication options but is hesitant to take opioid agonists. And so I've used this format for a lot of Zoom calls and really for Zoom in general because it's really easy just to have a table and just say, here's the most likely thing that's going to happen. Here's the worst thing that could happen. Here's the best possible scenario. But it's pretty typically done with palliative care. So for a patient like this, I would start by kind of just normalizing that this is the most common thing that occurs. 90% of people actually do not have any type of treatment for opioid use disorder. The best possible thing that could happen in this scenario would be sustained abstinence. So without any type of intervention at all, you would be able to actually no longer use opioids. Within this, you would also have to go through withdrawals, which would include things like diarrhea, nausea, headache, things that you've experienced in the past, as well as insomnia. And cravings to use will likely continue. And hopefully improve and be less severe as time goes on. The worst case scenario in this would be return to daily use or regular use. Which could lead to things like overdose, infection, or death. And although I'm really excited that you are interested in continuing to go upon the path of recovery, the most likely thing that actually happens with no medication, even with medications, is return to use with a severe opioid use disorder. So that's definitely worth highlighting. For medications like naltrexone, which is available as a one-month injection called Vibtrol, the best possible scenario is you would again have to go through withdrawals, which would be the exact same as if you didn't take any medication because you wouldn't be able to take the medication until you completed your withdrawal process. But following that, it would hopefully help prevent future overdose. It would hopefully reduce your cravings. And it would hopefully reduce your likelihood of returning to use. And keep you in actual treatment. The worst case scenario would be that something else happened entirely. You were in a car accident. Or you were in a large accident and you needed the intended effects of opioids for pain control. But because of the way that naltrexone works, you wouldn't be able to get that because it would be blocking the action of opioids. Because it would be blocking the action of opioids on your system. Which is a pretty big downside that we want to make sure we highlight. And then the other worst case scenario that we always want to mention with our patients is that about 1 in 100 patients has some kind of liver toxicity. And we're going to make sure we monitor for that by drawing labs and checking on your liver health. The most likely case is you might be about 1 in 4 people who has things like nausea from the medication. Let's see if I can spell nausea. A headache. Or some kind of constipation. Or abdominal pain. And you're of course going to have to complete the withdrawal from opioids as well. For buprenorphine, the best case scenario would be that you'd be able to avoid some of these things. You'd be able to avoid some of the severity of withdrawals you'd be getting with both naltrexone or with no medication at all. So minimal withdrawal. The best case scenario also would be that if you did return to use and continue taking this medication, it would actually help you prevent death. It's been shown to help prevent death. And also prevent overdose. And again, keep you in treatment. As well as help you actually have minimal cravings to use. The most likely things that happen when you're on this medication, very similar to naltrexone, you'd be probably about 1 in 4 people that have things like nausea. Oh, that's probably a bad spelling of nausea. Headache, constipation, or some kind of abdominal pain. And the worst case scenario would be, one, abrupt discontinuation. Which, leave that as it is. Which would actually put you in the same scenario as the initial best case scenario. For no medication. Where you'd be going through symptoms of withdrawal. It also does have an overdose risk that we definitely want to make sure we highlight with patients. with medications like benzodiazepines. And so it can make you at the same kind of risk for overdose, but not at the same level as you would be with an opioid agonist, such as fentanyl or heroin or any other type of opioid. And then, of course, with all medications, allergy. But I think what I really want to frame for you is that, although most people do not take any medications, most people do return to use, and it's the most likely thing that's going to occur. With these medications, they might help you both stay in treatment, stay in recovery, and the worst-case scenario for taking medications like buprenorphine or Suboxone is pretty similar to the best-case scenario at the initial part of not taking any medication. All right. And that's what I have there. I'm going to take it back to Jordan. Thank you so much, Myles. That was fantastic, and I learned extra from listening to you, as always. And just to even recap and connect this scenario that Myles just went through, this is a really beautiful example of a sort of curated piece that Myles would then be able to put directly into any kind of patient materials at the end of this visit, whether it's an after-visit summary or he's able to send it through some sort of patient portal. We mentioned MyChart a little bit earlier for those that use the EPIC system. But now what I think I'd like for us to do is, as a group, we're going to head into a little bit more of a discussion, is let's talk about how that went. So I'd love for you all to kind of brainstorm with me here about what seemed effective about this exercise that Myles just went through with his sort of imaginary patient. Yeah. I really love that you brought up a couple of key things, which is that it is really thorough and you do get to present sort of a clear visual menu to the patient. And then also the downside is maybe kind of curating that in the first place. Like, how do you know what information needs to be on the chart? What information are you putting in? What are you leaving out? Like, what kind of meets that criteria? And you're right that it would look so different, depending on what sort of conversation you're talking to your patient about, or at least what intervention you're talking to the patient about. Yeah. In the back. Yeah. I totally agree. And I think this came up earlier in our discussion of some of, like, the barriers and cons of using some of these tools, which is you do have this new, like, interruption between that patient, you know, rapport-building experience and your loss of eye contact and all the things that go into what we often consider to be very meaningful conversations, right? If you're staring at your computer and you're typing, you know, possibly you might lose something there. That's a really good point. Yeah. Yeah. That's a great point. Some of the differences in how this would look, depending on the actual structure of your encounter. So, in person, maybe you're seated side-by-side, you're looking at a piece of paper right next to them, versus the virtual platform, which is great for typing and looking at a screen at the same time, because they're all really, really neatly contained. Any other thoughts about things that seem to work well, or we talked a little bit about things that were difficult. Yeah. I think that's a really important point, too, because you're actually, on a day-to-day, going through, like, risks, benefits of alternatives, whether or not you're putting it out on paper for patients. And, at least for me, I always wonder if I say more than two sentences at a time if I said anything at all. And so, it's always nice to have, like, some concrete framework for the patient to return to, and so they're able to actually, like, take something forward with them, and not be either stuck with a package insert or what they remember from what you told them. Or what the pharmacist tells them last night when they're picking up their medications, and inevitably you get a message an hour later after your appointment with some more questions. But I think Miles made a great point, too, and this is all kind of leading towards some of the barriers kind of in this third question here, which is, how do you make this a tool that you can use? And how do you kind of support yourself in making that doable, right? How much prep work are you putting in? How much are you deciding to implement in these kind of, this sort of chalk talk format? And as Miles pointed out, too, you know, these are conversations that we're having versions of all of the time. And I think this is probably the most high yield of an activity if you think about the types of conversations that you tend to return to over and over with the people that you work with. And so, if you think about kind of, like, your high-frequency conversations, it seems like, you know, if you commonly prescribe SSRIs, you know, having some sort of conversation about what's the right choice for this particular patient that would be something that you already are talking about. And maybe it provides a good visual for your patient. Are there any other sort of circumstances or any kind of particular things that you can think of that you would be able to use this for that you kind of are already doing day to day? Yeah, I think that's a really beautiful point. In some ways, what you're doing is creating this sort of framework for your patient to then, you know, feel empowered to make the best choice for them as it applies to them, whether that's a medication or, you know, any other sort of therapeutic intervention or modality. I realize we all work with probably lots of different types of people in different situations. So, I think it's important that we think about this fairly broadly. And I know Myles did a really cool example with that, like, best outcome, worst outcome, and most likely outcome. But we can apply this to really any sort of thing that you find yourself talking to your patients about frequently. I know that I have certainly done several kind of behavioral chain analyses with some of my therapy patients before. And, you know, I've been able to send them to them. And they've really appreciated being able to kind of look at the work we did together in the session. And I think that's a little bit different from the example Myles went through, but it does kind of speak to that point of how do we engage with our patients as much as possible and provide them with kind of a copy of what we've done together. A couple things that we haven't brought up yet that I did want to make sure I really highlighted to make this feel more, or at least to kind of make this feel broadly doable for everyone, is that Myles basically gave a chalk talk to his patient. And it became kind of a tool to create a shared decision. And he used a pre-formatted template, like he had that chart just ready to go. And I think there was a question earlier about like how much time do you spend kind of making these or how do you have the resources ready to go? It's really simple to have like a Word document or some sort of material on your computer that you just pull up and you just start working from every single time. And it can be a chart like what Myles was using. It could be a framework for how it fits into like a behavioral model. It could be really anything that you again find yourself returning to, those high-frequency conversations. And then it also is really, really easy to put that directly into some sort of patient care material, whether you're copying and pasting it into an after-visit summary in a Zoom visit. Maybe you are even having your patient can take a picture of this if you've done something on a piece of paper together in person. I've had some patients who have taken a picture of worksheets that we've done together or even like in front of a whiteboard, which is, I think that was mentioned a little bit earlier, some of the dry-erase adventures that we've probably all done as well. But those are really, really transferable ways to kind of get the point across as well. I would like from this point to kind of move now to the exciting part of the day, which is our small group activity. We do have, I realize, one scattered and small group in the room. So I will encourage you to sort of choose your own adventure. If you would like to work on this individually, feel free to do so. If you maybe want to talk to the folks around you, that's also awesome. But we want to take about the next 20 minutes. I realize we put in groups of three, but we're going to say in groups of anonymous numbers. I want you to kind of take the opportunity to think about some sort of digital or in-person chalk talk that you might use with a patient. If you don't have patient populations that this really fits for, think about maybe something that you might like to deliver to trainees or any sort of teaching environments that you might find yourself in. We used a comment here about using whiteboard, paint, or Word. If you have a device with you and you want to use that, fantastic. If you want to pull up your phone, that's also a doable option. But we kept it with things that are very user-friendly that have kind of low activation energy, low learning curve that we've probably all used at some point or another at this point. And I put up some topics here that you can use. These are things that we thought of that may be clinically relevant. If that feels daunting, feel free to pick a topic that is absolutely irrelevant. It's a pretty low-risk activity, so maybe if you're a California native, Brian told us that In-N-Out and Shake Shack, it's very hotly contested. So I'd love to know if anyone has any strong opinions there, kind of regardless. But feel free to make your own topic, pick one of the ones we provided. And then after about 20 minutes, we'll kind of come back together and we'll talk as a group kind of how that process went. If anyone would like, they can also, you know, either present their Chalk Talk to the rest of the group or at least talk about what the main points of their theme were and we will go from there. Okay, so we'll take the next like 20 minutes or so and work on those. Was that a fast 20 minutes, folks? I feel like that's a sign of a good small group discussion if it feels like you're being yanked away too quickly. Yeah, right, when it says you have 60 seconds left and then like the shepherd's hook yanks you away. Well, thank you all so much for humoring us and reassembling and engaging in what sounded like some pretty great conversations. Let's just kind of take a second, and I just want to know what was that experience like just kind of thinking about where you might be able to implement some of these things in your day-to-day work? Yeah, that sounds like a fantastic idea. I love that. And I'm just thinking as well, oh yes, absolutely. So I'll try and summarize and just hold up a big red stop sign if I miss any of your salient points. There was just kind of a conversation about using LAIs and how to kind of generate some patient kind of buy-in with this technique about LAIs. This may be an understated goal of wanting to improve compliance with LAIs, but how to use some motivational interviewing techniques within that framework of the best outcome, worst outcome, most likely outcome, and have patients kind of fill in what their thoughts are about the different options or different outcomes, and then kind of filling in the gaps to kind of have patients also invested in the LAI process. I see some nods. Okay, great. Yeah, what other thoughts came up for folks as they were talking about things in their groups? Yeah, and then just to, I'm trying to repeat the things so we can all hear as well, but sounds like there were some identified barriers within your group about how do you have kind of the clear time and energy to kind of use this thing regularly. But I'm curious, I see lots of hands, but I'd love to know, well, yeah, we'll just start there. Go ahead. I love that. Chalk talks as an investment tool. That's great. I love that. Sorry, go ahead. Were there any other sort of like solutions or things that seemed like ways you could manage some of that tension, or maybe even how do you lower the activation energy for yourself? I can absolutely see, even if it feels like a very reasonable, practical investment, it's ready to go. Sometimes it's really tough, like you're seeing patients all day, and you may have back-to-back appointments, and it may, like, I can absolutely see how this would feel like something else that you have to generate and muster the energy for. It can be really tough and really draining. And so I think all of the things that have come up so far are very valid, but any, I see a hand kind of, yeah, yeah, absolutely, we love that idea, as trainees. Yeah, in the back. Yeah, that's a really beautiful idea. There's this, you make a bank of topics, you're sort of generating a curriculum, especially if you're going to teach the trainees, like, hey, these are conversations you're going to have with your patients in your clinic every single day, like, here's kind of a cheat sheet for yourself, and it really helps make this kind of part of your protocol in these kind of shared decisions that you're making with patients. That's awesome. We should do that. Yeah, and also the beauty of a shared drive, you don't even need a folder on your computer, and everyone can access it, and they're very usable. But I think even still, every hospital workroom does have a filing cabinet with some dusty forms that are not typically utilized. I know that I, many times, have been rifling through, looking for a piece of paper, and then I just end up Googling it after about five minutes. So I can definitely appreciate the beauty of some technology. Yeah, that's also a phenomenal idea. It's a quick way to generate that content in a really collaborative and efficient way. I'm also now thinking of things I wish I had done a year ago, but that's okay, that's okay. There we are. And our last bullet point here, we just kind of had volunteers to present, and I know we've kind of talked fairly openly about different topics and things that came up in your small group, so there's no burning pressure for anyone to stand up and give me the 10-minute chalk talk. But if anybody would like to mention any salient points from their conversations, or maybe some of the pros, cons about LAIs, I would love to know how those went. So maybe less about the content of what the material contains, and more about the process and how you're delivering it to the patient, and all the other kind of hidden curriculum that's in the room at any given point. Yeah, that's a really great point. We didn't really talk about things like biases when Miles gave his example, but that's a really beautiful thing to kind of bring up and make sure that we're being intentional about when we're having these conversations. Any other comments about any of these questions, or what that process felt like? Any other excellent ideas for residency programs? Something else, because I think that's a really great point. You learn so much in the process of making these kinds of things, even if you just made them for yourself and it wasn't a shared activity. I think what's really cool about this is that, I know we mostly focused today on interactions with patients and how we might use this in a clinic or hospital setting with a patient, but this can be expanded in so many different ways, even if you were thinking about key information that faculty often find themselves teaching to trainees or other learners. If you've ever supervised residents, how many times have you talked about, this is how we treat acute mania, these are the things that we do. If you had some sort of curriculum or curated content or bank of, these are the things that I want to make sure my trainees know about treatment of these acute things, or these are things that I want to make sure my residents know about how to assess for safety or effects of substances, or any other number of things, this can be used so broadly. We haven't even really talked as much about the therapy arm of things either, but it's a really unique process and thing that we can apply in so many different ways. Yeah, I totally agree with those points as well. And just in case, did everyone hear those, their comments? Okay, yeah, yeah. You are really good at learning how to learn in medical school, but not as good at teaching, but you have to learn it the hard way. So I think that using this as a tool is a really great point. I am keeping an eye on our time, which is like blowing by. So I think we can kind of segue towards just wrapping up. I would love to kind of, well, and we'll just revisit briefly our learning objectives, since we talked about some pros and cons of this whole process and how it can feel hard sometimes. It's a barrier in the room, but it's really adaptable. You can meet patients where they are and it's infinitely customizable. We did talk about three different kind of, or at least three, we talked about many different ways that you could use this as a tool or a resource. And then you had the opportunity to kind of explore this with your own small groups or even think about how you might want to use this in your day-to-day life. And with that, if anybody has other questions or take-home thoughts, or even if you just think about one thing that you're going to take home from this, feel free to share. Oh, yeah. Go ahead. Oh, yeah. I will type them. We're bolded and underlined. And thank you so much for such excellent discussions. I was really blown away and I learned a lot from you all as well. Thank you. Thank you. Thank you all for coming.

virtual learning

chalk talks

patient care

psychiatry education

interactive session

patient engagement

decision-making