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Welcome! Practice of Medicine (POM) INDE 201 Tracy Rydel, MD Jacqueline Tai-Edmonds, MD Course Director, POM Year 1 POM Quarter 1 Director Clinical Assistant Professor Clinical Assistant Professor General Medicine Disciplines General Medicine Disciplines (Family and Community Medicine) (Internal Medicine) Session Overview 1. 2. 3. 4. 5. 6. What is POM and your role in the course? Introductions to the POM team Communication Framework Demonstration Interview Debrief Wrap-up Learning Objectives At the end of this session, you will be able to: Understand the goals, expectations, and sequence of POM (INDE 201) Describe the different components of the INDE 201 course Identify key people on the POM team Developing a professional identity The journey has already begun Learning from one another “Every patient you see is a lesson in much more than the malady from which he suffers.” — William Osler, from The Student Life, in Aequanimitas What Does It Mean To Be A Physician? What Does It Mean To Be A Physician? Adult, life-long learning Collaborative learning Knowledge, skills, and self-awareness Awareness of the context of medical practice: the “themes” of POM What Does It Mean To Be A Physician? History Exam Patient Family Care Team Communities What is POM? Six-quarter course spanning two years Pre-clerkship preparation in: ◦ Clinical skills ◦ Clinical problem-solving ◦ Foundations of patient care… Foundations of Patient Care Ethics Epidemiology Evidence-based practice Nutrition Health policy Cultural awareness Psychiatry and behavioral science Public Health health policy psychiatry & behavioral science ethics public health information literacy epidemiology nutrition Patient – Physician multicultural medicine, CAM Desired outcomes in POM Conduct thorough patient interview Complete an accurate physical exam of an adult Synthesize findings Identify relevant signs & symptoms, abnormal tests Construct problem lists Begin to develop differential diagnoses Desired outcomes (continued) Discuss ethical/policy implications and ethical responsibility when science moves forward Define clinical questions and critically review literature Recognize health care challenges for elderly and other special populations Understand the impact of mental health on well-being Discuss nutrition in overall health and in prevention and treatment of obesity, cardiovascular disease, diabetes Act as change agent in informing health policy INTRODUCING… THE POM TEAM Biomedical Ethics Topic lead: ◦ Katrina Karkazis, PhD, MPH ◦ Danton Char, MD TA: ◦ Jason Batten Biomedical Ethics Topics ◦ Intro to Ethical Principles ◦ Privacy and Confidentiality ◦ Informed Consent and Capacity ◦ (additional topics Q3, Q6) image source: http://careers.bmj.com/careers/ advice/view-article.html?id=943 Format ◦ Video modules ◦ Case discussions Clinical Skills Topic lead: ◦ Jacqueline Tai-Edmonds, MD TAs: ◦ Nathaniel Fleming ◦ Mia Kanzawa Clinical Skills Topics – Q1 ◦ Medical interview ◦ Communication skills Format ◦ Small group, experiential ◦ Peer, SP, real patients ◦ Cardinal Free Clinic Population Health Topic lead ◦ Jennifer Newberry, MD, JD TA: Jecca Steinberg Coordinator: Jorge De Luna, MPH Office of Community Health Population Health Topics ◦ Individual to population Format ◦ Didactic, small group ◦ Community Engagement Experience image source: Exworthy M Health Policy Plan. 2008;23:318-327 Psychiatry Topic leads: ◦ Chris Hayward, MD, MPH ◦ Yasmin Owusu, MD Psychiatry Topics ◦ ◦ ◦ ◦ Behavioral Determinants of Health Evaluating Alcohol and Drug use Communication Breakdown Strategies Models and Access to Psychiatric Care Format ◦ Didactic ◦ Patient interview observation source: Addiction Medicine: Closing the Gap between Science and Practice. The National Center on Addiction and Substance Abuse at Columbia University. June 2012. Quantitative Medicine Topic lead: ◦ Rita Popat, PhD TA ◦ Justin Norden Quantitative Medicine Topics ◦ Clinical Epidemiology ◦ Biostatistics Format: Blended ◦ Video modules ◦ Quizzes ◦ In-class application sessions Nutrition Topic lead: Christopher Gardner, PhD Nutrition Topics ◦ National Recommendations ◦ Food Inadequacy Format ◦ Didactic / case vignettes ◦ Online modules 2011 1946 INDE 201 Faculty and Staff Tracy Rydel, MD Madika Bryant, MA Kambria Hooper Evans, MEd, MA INDE 201 TAs Jason Nathaniel Justin Mia Chase Jecca Relationship between E4C and POM E4C Foundations of Patient Care Clerkship teaching Mentoring Advising Pre-Clerkship Clinical Skills Teaching Standardized Patient POM Core Faculty POM Standardized Patient Program (photos via Stanford Ed Tech) Practical Details Syllabus ◦ Coursework: Schedule, assignment, readings ◦ Course requirements, grading, & exam ◦ Equipment: Stethoscope, pen light, ophthalmoscope/ otoscope, reflex hammer ◦ Assignment, attendance policy ◦ Dress code, professionalism, confidentiality Universal Precautions and Needlestick Policy Small group assignments HIPAA certification completion: In-class patient interview TODAY Where am I going on Monday? 2015-16 INDE W MON 8:00-13:30 13:30-14:20 14:30-15:50 16:00-17:20 Quantitative Medicine: Overview and Introduction (LK130) Population Health: Introduction to Clinical Skills: Opening and HPI Population Health (LK102) (LK203/LK204, LK205/206, LK208, LK209) Clinical Skills: Opening and HPI Population Health: Introduction (LK203/LK204, LK205/206, to Population Health (LK102) LK208, LK209) TU Dates to note Thanksgiving Break = November 23-27 End-of-Quarter Standardized Patient Assessment ◦ Week of November 30-December 4, Immersive Learning Center Written Final Examination ◦ Tuesday, December 8, 9:30 am – 12:30 pm, LK120/130 Looking Ahead: First day of Quarter 2 ◦ Monday, January 4, 2016 Equipment Universal Precautions Protect you and your patients • Reduce the risk of transmission of infectious agents from recognized and unrecognized sources • Apply to the handling of blood, body fluids*, and human tissue • **Universal = use on ALL patients** Universal Precautions Use: • • • • Hand-washing Mask, eye protection, face shield Gloves Gown In handling: • • • • Patient care equipment Linens Needles, sharp instruments Direct patient care Needlestick Protocol If you believe you have had a significant exposure to blood or other potentially infectious material (OPIM): • IMMEDIATELY wash wound or exposed tissue thoroughly with soap and water. • Rinse copiously. • Call The Exposure and Needle Stick hotline • 650-723-8222 then pager 1-STIX • 222 then 1-STIX from hospital or medical school phone Needlestick Protocol • You will talk to a staff person 24/7 who is trained and on call specifically for this purpose. This hotline has been set up for medical students and Stanford employees. • There is no charge for blood tests, medications, or follow-up care following a blood or OPIM exposure. • Records are confidential in accordance with applicable laws. Take home points Develop your professional identity Promote teamwork Value life-long learning: ◦ mentors, peers, and patients Develop a toolkit of skills Practice, practice, practice! Questions COMMUNICATION MATTERS: THE ART AND SCIENCE OF TALKING WITH PATIENTS Learning Objectives At the end of this session, you will be able to: 1. Discuss the importance of effective communication in the medical interview 2. Describe 3 functions of the medical interview 3. Identify specific behaviors within those 3 functions 4. Give productive feedback on that interview The Medical Interview: Importance Core clinical skill Communication skills are not innate or fixed Skills can be learned and improved Improve clinical accuracy and outcomes by learning how and when to use specific communication techniques Maiman, 1988 Lipkin, 1997 Communication Impact Diagnosis • Adherence • Patient health • Patient satisfaction • Physician satisfaction • Malpractice litigation • Framework for the Medical Interview Three functions: 1. Building the patient-physician relationship 2. Assessing the patient’s problems 3. Managing the patient’s problems 1. Build a Relationship Patient-centered model Physician-Patient partnership Families, support networks, communities image source: https://www.visitorpasssolutions.com 1. Build the Relationship: Emotion Handling Partnership Empathy Apology Respect Legitimization Support Coulehan et al, Ann Intern Med 2001;135:221-7; Suchman et al, JAMA 1997;277:678-682. 2. Assessing the Patient’s Problem Goal: “collect accurate, sufficient, and relevant data from the patient in as efficient manner as possible” Accurate diagnosis and treatment? Efficiency vs. accuracy image source: http://www.letshavefunwithenglish.com 2. Assessing the Patient’s Problem: Tools Allow the patient to complete his/her opening statement Elicit the full spectrum of patient concerns ◦ “Door knob questions” Marvel, et al, JAMA 1999;281:283-287 2. Assessing the Patient’s Problem: Tools Open- to closed-ended questioning Begin with eliciting the initial story Active listening, minimize interruptions Clarify, summarize, review to check facts of the story, invite more 3. Managing the Patient’s Problem Diagnose Educate Negotiate a Plan image source: http://www.medicinenet.com End'Quarter'SP'Assessment Bringing'It'All'Together Intimate'Partner'Violence Challenging'Patient'Encounter Motivational'Interviewing Structural'Factors'in'Chronic'Illness'Management Third:Party'Interviewing Sharing'Information Review'of'Systems Social'History'#2 Social'History'#1 Past'Medical'and'Family'Medical'History Opening'and'HPI Baseline'Standardized'Patient'Encounter Good Communication Easy rule to live by– the patient in front of you is someone’s mother, father, daughter, son, brother, or sister You are entrusted with this person’s health and livelihood Interview observation Write down specific examples of physician behaviors in each of “three functions” ◦ Building relationship ◦ Assessing problems ◦ Managing problems Feedback Keep Stop Start