FM Clerkship Project Slide Templates Things to Consider: Create a - - PDF document

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FM Clerkship Project Slide Templates Things to Consider: Create a title that is representative of your content, as well as sparks interest in your audience. Things to highlight:

• who does this problem

affect?

• in what ways does this

problem affect the individual or community? Brief overview of FIFE

• what has been tried so

far?

• what have been the results
• f these efforts?

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Things to Consider:

• PICO structure to refine

your question (Patient/Population or Problem, Intervention, Comparison intervention, Outcomes)

• searching databases and

journals that are relevant to Family Medicine, Population Health, and the identified health challenge

• see

http://libguides.ucalgary .ca/family_med Appendix 5 below

• Level of available

evidence (Sackett‟s criteria 1-5) and critical appraisal of resources used Things to Consider:

• Patient-Centred Clinical

Method “PCCM”(Stewart et al, 2003)

• Proximal factors in

context: family, financial security, education, employment, leisure, and social support Distal factors in context: community, culture, economics, healthcare systems, socio-historical, geography, the media and ecosystem health

• more thorough

exploration of FIFE

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Things to Consider: Any features of the community which (may) have an impact on the Health Challenge, creating a barrier or a bridge to wellness. e.g.

• availability of indoor

recreation space, including hours, universal accessibility (wheelchair ramps), cost

• community bylaws

regarding snow clearance if health challenge

• outdoor air quality related

to agriculture or other industry Things to consider:

• revisiting your initial

literature search (“What‟s known in the Universe”) and apply what you‟ve learned about your patient‟s key contextual features to refining and/or re-directing your search.

• exploring government

documents; community medicine, anthropology or sociology literature; community-based resources

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Things to Consider:

• ”benefits” may include

reduced mortality, preserved function, improved quality of life, etc…

• ”drawbacks” may include

financial cost, adverse effects of medications, time commitment, etc…

• if available and relevant to

your individual or community health challenge, include quantitative expressions of benefit/drawbacks, e.g. NNT, Absolute risk reduction Things to Consider:

• this should be done at a

follow-up visit, after you‘ve searched the literature

• PCCM identifies 3 Key steps

to Finding Common Ground with patients:

• 1. ―Defining the problem‖ in

terms that include both the disease process and patient‟s illness experience

• 2. ―Establishing the goals

and priorities of management‖ putting the patients values at the forefront

• 3. ―Identifying the roles to

be assumed by both patient and doctor‖ie. who will do what and what to do if the unexpected happens (safety nets) For a Community Health Challenge, outline specific interventions that you can justify to your peers that make sense for the health challenge and community context you‟ve presented and if possible, discuss these with someone representative of the community under study.

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Some concepts to consider when doing your project…

• A. Narrative Approach

We all use stories to make sense of our experiences. The more stressful the experience, the more we need to tell and re-tell our story. When physicians listen intently, by using reflective methods and empathy, they build the patient‟s trust and can begin the process of healing. Phrases that invite patients to tell their stories, such as “Tell me, from when this first started, what you‟ve been noticing…”, give patients the opportunity to provide detailed information that naturally integrates the description of the disease process and their unique illness experience. A careful and active listener, who is skilled in this approach, can efficiently gather the information needed to understand “the whole person” (see below) while developing strong rapport with their patient. An excellent example

• f a patient‟s narrative can be found at:

http://www.vancouversun.com/health/Cancer+best+thing+that+ever+happened/2752354/story.html

• B. Understanding the ―Whole Person‖
• requires integration of 3 concepts:

1.) Disease Process

• the biophysical nature of the health challenge is revealed by conventional clinical

methods which focus on History, Physical Exam, lab tests and other investigations. AND

2.) Illness Experience

• “FIFE”, an approach used in pre-clerkship Med Skills, can be used to think about

an individual‟s unique experience of illness, FIFE: Feelings about being ill (including Fears) Ideas about the illness-the patient‟s explanatory model and the meaning of the illness Functional impact of the illness Expectations of the visit/physician (see Calgary-Cambridge Guides 1 and 2 (CCG), Appendix 2 and 3) AND

3.) Context:

• many elements of a patient‟s context may be revealed by a conventional “Personal Social

History”, including occupation, home situation and habits. The ―Patient-Centred Clinical Method‖ (PCCM) (Stewart et al, 2003), pioneered in the 1980‟s and ever-evolving, encourages a richer understanding of an individual‟s or community of patients‟ “context”. This typically requires several visits

• ver time (continuity of care really helps here…) and preceptors may be able to provide much of this detail..

The PCCM recognizes the key role of:

• a. Proximal factors in context include personality, current life stage, past experiences, spirituality,

family dynamics, financial security, education, employment, leisure, and social support.

• b. Distal factors in context include community, culture, economics, healthcare systems, socio-

historical, geography, the media and ecosystem health. For further details of PCCM:

• 1. Appendix 4 of Core Doc
• 2. “Patient-Centred Medicine: transforming the clinical method” M Stewart et al, 2003
• n reserve in the Health Sciences Library; a useful excerpt from this text is at

http://www.uwo.ca/fammed/ian/patcen.htm

• 3. Patient-Centred Interviewing Parts I to III

http://www.ncbi.nlm.nih.gov/pmc/issues/162784/

• 4. “Tell me about yourself: The Patient-Centered Interview” F Platt et al, Ann Intern
• Med. 2001; 134: 1079-85

http://www.annals.org/content/134/11/1079.full.pdf+html

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• C. Finding Common Ground

“CCG Two – Explanation and Planning” provides many detailed points to assists students in finding Common Ground with patients. PCCM describes finding common ground as “the process through which the patient and doctor reach a mutual understanding and mutual agreement in three key areas: defining the problem; establishing the goals and priorities of management; and identifying the roles to be assumed by both the patient and the doctor.

Example:

John, aged 79, was a creature of habit, who lived alone but enjoyed walking “uptown” several times a week, for his groceries, to go to the bank, and to have a soda at the legion. He had come in to follow-up after recent discharge from hospital for his first bout of urosepsis in a year. John was diagnosed 3 years ago with high grade, localized bladder cancer requiring resection and creation of an ileal pouch that drained urine via an ostomy. John declined the recommended adjuvant chemotherapy and radiation therapy, on the basis of his prior experiences with his wife and mother, whose battles with cancer and chemo were terrible. John eventually adjusted to the ostomy, managing bag changes independently but always complained about taking any medication. He disliked the taste, the required schedules and saw “pills” as a sign of weakness. Following his bladder resection, John developed benign ureteral strictures on his right side which led to several bouts of urosepsis, requiring hospitalization. He struggled with each admission to hospital, associating these times with his wife’s and mother’s final days. After much discussion, he agreed to the recommended right

• nephrectomy. Following this surgery, John did well until this most recent bout of infection. Infectious disease specialists

recommended daily prophylactic antibiotics to try to prevent recurrent urinary infection. “More pills” was not welcomed by John but neither was repeated hospital admission. John’s main priority now, in fact, was to reach his 80th birthday, 6 months away. He described the party already being planned by his eldest of 5 children, a daughter who lived locally and whom he saw sporadically, describing her as “nosey”. With this priority in mind, John and his physician reviewed his medication list and agreed that a trial off

• f his iron and calcium supplements, as well as his proton pump inhibitor (previously prescribed for GERD) was not unreasonable to

reduce his pill burden, making the daily prophylactic antibiotic more palatable. He also agreed to alert his physician at the first signs of trouble with his remaining kidney, so that oral treatment might be tried, in hopes of avoiding repeat admission. In the past, John had always held off as long as possible, before coming to the office, essentially denying there was a significant problem, hoping it would go away on its own. His previous priority was to avoid hospital admissions and doctors. As he came to trust his physician

• ver time, he was more willing to “come early”, knowing that everything would be done to avoid hospital admission as well as to

support his goal of reaching his 80th birthday.

Key area of Finding Common Ground Relevant CCG Two Points 1.) Defining the problem

• in terms that include both the disease process and patient‟s illness

experience

Providing the correct amnt/type of info (1-5) Aiding accurate recall/understanding (6-11) Discussing opinion/signif of problem (22-26)

2.) Establishing the goals and priorities of management

• putting the patient‟s values at the forefront

Planning: shared decision-making (16-21) Negotiating mutual plan of action (27-33) Discussing investigations/procedures (34-36)

3.) Identifying the roles to be assumed by both patient & doctor

• as next steps are taken, who will do what, safety nets if things go

amiss

Forward planning (37-38) Ensuring appropriate point of closure (39-40)