Discussion of SP Case. Agenda Discussion of SP case Discussion of SP case Review key principles of clinical medicine Review key principles of clinical

Discussion of SP Discussion of SP CaseCase

AgendaAgenda

Discussion of SP caseDiscussion of SP case Review key principles of clinical Review key principles of clinical

medicinemedicine Andrea Milam: Moral reasoning, Andrea Milam: Moral reasoning,

course/program evaluation, researchcourse/program evaluation, research Course evaluation: Defining issues Course evaluation: Defining issues

testtest

The Medical InterviewThe Medical Interview

Not a one-way interrogationNot a one-way interrogation

It is a two-way collaborative and It is a two-way collaborative and dynamic interactiondynamic interaction

The Medical InterviewThe Medical Interview

Most important part of the medical Most important part of the medical encounterencounter

FunctionsFunctions Structure, content, processStructure, content, process Requires communication and Requires communication and

interpersonal skillsinterpersonal skills

What are the functions of What are the functions of the medical interview?the medical interview?

Functions of the Medical Functions of the Medical InterviewInterview

Build the relationshipBuild the relationship Assess the patient’s problemsAssess the patient’s problems Manage the patient’s problems Manage the patient’s problems

(education, negotiation, motivation)(education, negotiation, motivation)

What is the basic structure What is the basic structure of the medical encounter?of the medical encounter?

Structure and Tasks of the Structure and Tasks of the Medical EncounterMedical Encounter

Initiate the sessionInitiate the session Gather informationGather information Explaining and Explaining and

planningplanning Closing the sessionClosing the session

Building the Building the relationshiprelationship

Provide structure Provide structure to the encounterto the encounter

ProvidingStructure

Initiating the Session

Closing the Session

Physical Examination

Explanation and planning

Gathering information

Building the relationship

Initiating the Session: Initiating the Session: StudentsStudents

How did you initiate the session?How did you initiate the session? What were you trying to accomplish?What were you trying to accomplish? What steps did you take?What steps did you take?

Initiating the Session: Initiating the Session: SPsSPs

How did they do?How did they do?

Initiating the SessionInitiating the Session

PreparationPreparation Establishing initial rapportEstablishing initial rapport Identifying the reason(s) for the Identifying the reason(s) for the

encounter encounter

PreparationPreparation

Puts aside last task, attends to self Puts aside last task, attends to self comfort comfort

Focuses attention and prepares for Focuses attention and prepares for this encounterthis encounter

Opening the InterviewOpening the Interview

ObjectivesObjectives Establish Establish supportive environmentsupportive environment

and initial and initial rapportrapport Awareness of Awareness of pt’s emotional statept’s emotional state ID all pt’s issues/problemsID all pt’s issues/problems he/she he/she

wishes to addresswishes to address Negotiate agendaNegotiate agenda for encounter for encounter Develop partnershipDevelop partnership with pt with pt

Opening the InterviewOpening the Interview

ConveyConvey RespectRespect EmpathyEmpathy SupportSupport Non-judgmentaNon-judgmental/unconditional l/unconditional

positive regardpositive regard InterestInterest in the patient as an in the patient as an

individualindividual

Opening the InterviewOpening the Interview Greet the patientGreet the patient Verify/obtain pt’s nameVerify/obtain pt’s name Introduce self and Introduce self and

clarify role and goals of clarify role and goals of interviewinterview

Obtain pt’s consent for Obtain pt’s consent for interviewinterview

Attend to patient’s Attend to patient’s comfortcomfort

Initial rapport-building Initial rapport-building skillsskills

Identify the reason(s) Identify the reason(s) why the patient came why the patient came to the doctorto the doctor

Negotiate prioritiesNegotiate priorities Elicit the patient’s Elicit the patient’s

expectationsexpectations









Initial Rapport Building Initial Rapport Building SkillsSkills

Initial non-verbal communicationInitial non-verbal communication RespectRespect Attending to patient’s comfortAttending to patient’s comfort Engage the patientEngage the patient



What percent of What percent of communication is non-communication is non-

verbal?verbal?

What percent of What percent of communication is non-communication is non-

verbal?verbal?

Around 80%

Nonverbal Nonverbal CommunicationCommunication

Facial ExpressionsFacial Expressions Physical Physical

EnvironmentEnvironment Territory and Territory and

Interpersonal Interpersonal SpaceSpace

Body LanguageBody Language ParalanguageParalanguage TouchTouch

Nonverbal Nonverbal CommunicationCommunication

“You’re my doctor???!!”

RapportRapport

RapportRapport

Rapport is one of the most important Rapport is one of the most important features or characteristics of human features or characteristics of human interaction. interaction.

It is commonality of perspective, It is commonality of perspective, being in "sync", being on the same being in "sync", being on the same wavelength as the person you are wavelength as the person you are talking to. talking to.

What Are Rapport Skills?What Are Rapport Skills?

Start with greeting and getting to Start with greeting and getting to know the pt or checking how the pt know the pt or checking how the pt is doingis doing

Many are nonverbal expressing Many are nonverbal expressing interest and concerninterest and concern

““Positive talk” personally supportivePositive talk” personally supportive Avoiding “negative talk” criticism, Avoiding “negative talk” criticism,

blaming, arrogance blaming, arrogance

Lang

Rapport: Pros Rapport: Pros

Shows interest in the pt as a personShows interest in the pt as a person Initial non-clinical talk helps Initial non-clinical talk helps

calibrate the future communication calibrate the future communication style, language, spontaneitystyle, language, spontaneity

For non-emergent care in an For non-emergent care in an emergency setting, pts still emergency setting, pts still frequently appreciate personal frequently appreciate personal interest at the beginning of the interest at the beginning of the interviewinterview

Lang

Rapport: ConsRapport: Cons

On occasion, a pt in an ambulatory On occasion, a pt in an ambulatory setting will want to “get right down setting will want to “get right down to business”to business”

Frequently in emergency situations Frequently in emergency situations pts want their disease taken care of pts want their disease taken care of firstfirst

If insincere or overdone, positive If insincere or overdone, positive talk can appear like “kissing up”talk can appear like “kissing up”

Lang

Barriers to Use of Rapport Barriers to Use of Rapport BuildingBuilding

In an effort to be “professional”, some In an effort to be “professional”, some students may avoid a relaxed, personally students may avoid a relaxed, personally interested postureinterested posture

Gender issues may create a fear that Gender issues may create a fear that personal interest may attract unwanted personal interest may attract unwanted personal advancespersonal advances

The interviewer may have negative The interviewer may have negative personal feelings or experiences with personal feelings or experiences with regards to the pt or clinical situation regards to the pt or clinical situation (counter-transference)(counter-transference)

Lang

Genuineness and Respect Genuineness and Respect are the Key are the Key

GenuinenessGenuineness - "Be truthful about who you - "Be truthful about who you are personally and professionally. Learn are personally and professionally. Learn to compartmentalize your personal and to compartmentalize your personal and professional selves." professional selves."

RespectRespect - "Be nonjudgmental. Convey - "Be nonjudgmental. Convey unconditional positive regard. Value the unconditional positive regard. Value the other person as an individual even if you other person as an individual even if you don't like them."don't like them."

Bayer



Rapport Building Skills:Rapport Building Skills:Engage the PatientEngage the Patient

Engage DefinedEngage Defined

A connection which continues A connection which continues throughout the encounterthroughout the encounter

Person-to- personPerson-to- person Professionally, as partnersProfessionally, as partners

Bayer

Engagement: TechniquesEngagement: Techniques

Join the patientJoin the patient Use the first few minutes to build Use the first few minutes to build

rapportrapport Use a pleasant, consistent tone of Use a pleasant, consistent tone of

voicevoice

Bayer

Engagement: TechniquesEngagement: Techniques

Be as curious about the person as you are Be as curious about the person as you are their medical conditiontheir medical condition

““Care more particularly for the individual Care more particularly for the individual patient than for the special features of the patient than for the special features of the disease”disease”

Sir William OslerSir William Osler

Examples of “Non-Medical” Examples of “Non-Medical” Conversation TopicsConversation Topics

Begin the interview with a personal inquiry, for Begin the interview with a personal inquiry, for example:example: Ask about something in the patient’s background that Ask about something in the patient’s background that

catches your interestcatches your interest Identify a shared interest, experience, or backgroundIdentify a shared interest, experience, or background Engage in small talkEngage in small talk

Ask about demographic data, such as name, age, Ask about demographic data, such as name, age, occupation, and marital statusoccupation, and marital status

Ask about the patient’s general health before Ask about the patient’s general health before asking the reason for the visit.asking the reason for the visit.

Find something you like about each patientFind something you like about each patient

(Billings and Stoeckle,1999)(Billings and Stoeckle,1999)

Building RapportBuilding Rapport

New patient:New patient: ““Before we begin, tell me something Before we begin, tell me something

about yourself.”about yourself.”

Return patient:Return patient: Mention something personal from a Mention something personal from a

previous visitprevious visit









Identify the Reason(s) why Identify the Reason(s) why the Patient came to the the Patient came to the

DoctorDoctor StudentsStudents

Why did the patient come to the doctor?Why did the patient come to the doctor?


DoctorDoctor SPsSPs

Why did you come to the doctor?Why did you come to the doctor?


DoctorDoctor Most patients have more than one Most patients have more than one

concern (mean around 3 concerns)concern (mean around 3 concerns)

The first concern may not be the The first concern may not be the most important to the patientmost important to the patient

Identifying all pt’s concerns allows Identifying all pt’s concerns allows for time allocationfor time allocation

Skills:Skills: Identifying the reason(s) for Identifying the reason(s) for the patient’s visitthe patient’s visit

The opening question:The opening question: identifies the identifies the problems or issues that the patient wishes problems or issues that the patient wishes to address (e.g. “What would you like to to address (e.g. “What would you like to discuss today?”)discuss today?”)

Listening to the patient’s opening Listening to the patient’s opening statement:statement: listens attentively without listens attentively without interrupting or directing patient’s interrupting or directing patient’s responseresponse

Skills:Skills:Identifying the reason(s) for the Identifying the reason(s) for the

patient’s visitpatient’s visit

Screening:Screening: checks and confirms list of checks and confirms list of problems or issues that the patient wishes to problems or issues that the patient wishes to covercover (e.g. “so that’s headaches and tiredness, is there (e.g. “so that’s headaches and tiredness, is there

anything else you’d like to discuss today as anything else you’d like to discuss today as well?”)well?”)

Agenda settingAgenda setting:: negotiates agenda and negotiates agenda and format of interview taking both patient’s and format of interview taking both patient’s and physician’s needs into account physician’s needs into account

ProvidingStructure


Closing the Session




Building the relationship

Gathering InformationGathering Information

StudentsStudents Tell us about the patient’s abdominal Tell us about the patient’s abdominal

painpain Tell us what information you gathered Tell us what information you gathered

on this patient’s past and current on this patient’s past and current ongoing medical problemsongoing medical problems

What other information about this What other information about this patient you feel is pertinent?patient you feel is pertinent?


SPsSPs How did the students do?How did the students do? Did they miss any pertinent Did they miss any pertinent

information?information? Did they gather information to Did they gather information to

understand your perspective?understand your perspective?

Content of the Medical Content of the Medical HistoryHistory

Chief complaint and survey of Chief complaint and survey of problemsproblems

History of present illnessHistory of present illness Past medical historyPast medical history Family historyFamily history Patient profile and social historyPatient profile and social history Review of systemsReview of systems

Chief complaint and survey Chief complaint and survey of problemsof problems

The one or more concerns causing The one or more concerns causing the patient to seek care.the patient to seek care.

Encourage the pt to tell you Encourage the pt to tell you allall of of his/her concerns.his/her concerns.

You may negotiate what will be You may negotiate what will be covered due to time limitationscovered due to time limitations

History of Present IllnessHistory of Present Illness

Amplifies each of the patients Amplifies each of the patients concerns.concerns.

Includes the patient’s thoughts and Includes the patient’s thoughts and feelings about the illness.feelings about the illness.

The narrative threadThe narrative thread


Seven content itemsSeven content items::1.1. LocationLocation: : Where does it hurt?Where does it hurt?2.2. QualityQuality: : What does it feel like?What does it feel like?3.3. SeveritySeverity: : How bad is it?How bad is it?4.4. TimingTiming: : When did it start? How long does it When did it start? How long does it

last?last?5.5. ContextContext: : What were you doing when it first What were you doing when it first

began?began?6.6. Modifying factorsModifying factors:: Does anything make it Does anything make it

better or worse?better or worse?7.7. Associated symptomsAssociated symptoms: : What other symptoms What other symptoms

are associated with this problemare associated with this problem


Patient’s perspective of the illnessPatient’s perspective of the illnessFIFEFIFEF F = = FunctionFunction: : How has this affected you?How has this affected you?I I = = IdeasIdeas: : What do you think caused What do you think caused

this this problem?problem?F F = = Feelings:Feelings: What concerns you about What concerns you about

this problem?this problem?EE = = Expectations: Expectations: How to you hope we How to you hope we

can help you with this problem?can help you with this problem?

Past Medical HistoryPast Medical History

An exploration of the person’s overall health An exploration of the person’s overall health before the present problem, including all past before the present problem, including all past medical and surgical experiences.medical and surgical experiences.

Past Medical HistoryPast Medical History HospitalizationsHospitalizations SurgeriesSurgeries IllnessesIllnesses TraumaTrauma MedicationsMedications AllergiesAllergies PregnanciesPregnancies TransfusionsTransfusions ExposuresExposures

Past Medical HistoryPast Medical History

Health MaintenanceHealth Maintenance Periodic health examinationsPeriodic health examinations ImmunizationsImmunizations Injury preventionInjury prevention ExerciseExercise

Family HistoryFamily History

An exploration of a family’s health, past An exploration of a family’s health, past medical experiences, illnesses, social medical experiences, illnesses, social experiences, deaths, and genetic and experiences, deaths, and genetic and environmental circumstancesenvironmental circumstances

Family HistoryFamily History

Current health of parents, siblings, and Current health of parents, siblings, and childrenchildren

History of significant illnesses in the family, History of significant illnesses in the family, such as hypertension, diabetes, coronary artery such as hypertension, diabetes, coronary artery disease, etc.disease, etc.

Social HistorySocial History

Information that helps in the Information that helps in the understanding of the patient as an understanding of the patient as an individual individual

Helps to begin to get a view of the Helps to begin to get a view of the patient’s illness in the context of patient’s illness in the context of his/her lifehis/her life

Social HistorySocial History

Patient profilePatient profile Place of birth and upbringing, Place of birth and upbringing,

education, military, occupations, education, military, occupations, hobbieshobbies

Living situations, family, and Living situations, family, and relationships, residencerelationships, residence

Impact of illness on lifeImpact of illness on life

Health-risk behaviorsHealth-risk behaviors Life-stress and satisfactionLife-stress and satisfaction

Review of SystemsReview of Systems

Assesses for the presence or Assesses for the presence or absence of common symptoms absence of common symptoms related to each major body systemrelated to each major body system

Review of SystemsReview of Systems General/constitutionalGeneral/constitutional SkinSkin EyesEyes ENTENT PulmonaryPulmonary CardiovascularCardiovascular DigestiveDigestive GenitourinaryGenitourinary HematologicalHematological ImmuneImmune EndocrineEndocrine MusculoskeletalMusculoskeletal NeurologicalNeurological PsychiatricPsychiatric

History of Present IllnessHistory of Present IllnessStudents: For this patientStudents: For this patient






History of Present IllnessHistory of Present IllnessSPsSPs






History of Present IllnessHistory of Present IllnessStudents: For this patientStudents: For this patient





History of Present IllnessHistory of Present IllnessSPs SPs






SkillsSkills

Skills: Gathering information: Skills: Gathering information: Exploration of ProblemsExploration of Problems

Encourages Encourages the patient to tell story the patient to tell story

(narrative)(narrative) Uses Uses open-endedopen-ended and closed-ended and closed-ended

questions, appropriately moving from open-questions, appropriately moving from open-ended to closed, non-directive to directiveended to closed, non-directive to directive

Avoids or explains jargonAvoids or explains jargon, avoids other , avoids other language “pitfalls”language “pitfalls”

Listens Listens attentively, allowing patient to attentively, allowing patient to complete statements without interruption complete statements without interruption and leaving space for patient to think and leaving space for patient to think before answering or go on after pausingbefore answering or go on after pausing

ListeningListening

ListeningListening

““Listening to a patient narrative is Listening to a patient narrative is also observing. Here, what the also observing. Here, what the patient actually said and the exact patient actually said and the exact manner - words, pausing, pitch, manner - words, pausing, pitch, emphasis, and so on - in which it is emphasis, and so on - in which it is said is the observation that must be said is the observation that must be separated from what the listener separated from what the listener thinks the patient meant”thinks the patient meant” Eric Cassell, MDEric Cassell, MD

ListeningListening

Doctors hope they are good listeners Doctors hope they are good listeners already. But how often do we really already. But how often do we really listen?listen?

How often do we anticipate what is How often do we anticipate what is

going to be said next, and jump in going to be said next, and jump in with our thoughts and ideas as soon with our thoughts and ideas as soon as there is a pause?as there is a pause?

ListeningListening

Listening is an art, a skill, and needs Listening is an art, a skill, and needs to be learned and practiced. to be learned and practiced.

As listeners we need to be warm, As listeners we need to be warm, caring and non-judgmental. caring and non-judgmental.

We need to make a special effort to We need to make a special effort to tune in to the person’s feelings, and tune in to the person’s feelings, and have a genuine respect for the person have a genuine respect for the person calling.calling.

Effective listeningEffective listening

There are three components in There are three components in effective listening:effective listening:

Attending behaviorAttending behavior Effective use of silence (wait time)Effective use of silence (wait time) Active listeningActive listening

Listening: Attending Listening: Attending BehaviorBehavior

Eye contactEye contact Body languageBody language Tone of voiceTone of voice Following the conversationFollowing the conversation

This means that you do not interrupt, or This means that you do not interrupt, or change the subject or introduce new topics.change the subject or introduce new topics.

Attending well will mean that the patient Attending well will mean that the patient does most of the talking, and that you don’t does most of the talking, and that you don’t lecture..lecture..

Active ListeningActive Listening

FacilitationFacilitation - encourage client to - encourage client to continue; “uh-huh”continue; “uh-huh”

ClarificationClarification - obtain more info; - obtain more info; “What do you mean by -------- ?”“What do you mean by -------- ?”

RestatementRestatement - repeating what was - repeating what was said using different wordssaid using different words

Active ListeningActive Listening

ReflectionReflection - repeating what the - repeating what the patient just said to encourage patient just said to encourage elaborationelaboration

InterpretationInterpretation - used to share a - used to share a conclusion drawn from dataconclusion drawn from data

SummarySummary (checking)- condenses & (checking)- condenses & orders data for sequencing eventsorders data for sequencing events

Listening With EmpathyListening With Empathy

Empathy is Empathy is understandingunderstanding Empathy is Empathy is notnot sympathy sympathy Sympathy is an expression of one’s Sympathy is an expression of one’s

own own feelings about another’s feelings about another’s predicamentpredicament

Empathy is an attempt to fell Empathy is an attempt to fell with with another person, to understand their another person, to understand their point of view. point of view.

Skills: Gathering information: Skills: Gathering information: Exploration of ProblemsExploration of Problems

FacilitatesFacilitates patient’s responses verbally and patient’s responses verbally and

non-verbally (use of encouragement, silence, non-verbally (use of encouragement, silence, repetition, paraphrasing)repetition, paraphrasing)

ClarifiesClarifies patient’s statements which are patient’s statements which are vague or need amplification (e.g. “Could you vague or need amplification (e.g. “Could you please explain what you mean by please explain what you mean by ‘lightheaded’?”‘lightheaded’?”

ChecksChecks with patient to insure understandingwith patient to insure understanding Helps the patient Helps the patient organizeorganize the narrative the narrative

thread, checks dates, helps establish thread, checks dates, helps establish chronology, directschronology, directs

Skills: Gathering information: Skills: Gathering information: Understanding the patient’s Understanding the patient’s

perspectiveperspective Function:Function: determines how each problem affects determines how each problem affects

the patient’s lifethe patient’s life Ideas:Ideas: determines and acknowledges patient’s determines and acknowledges patient’s

ideas (i.e. beliefs regarding cause) regarding ideas (i.e. beliefs regarding cause) regarding each problemeach problem

Feelings and thoughtsFeelings and thoughts:: encourages expression encourages expression of the patient’s feelings (i.e. worries)of the patient’s feelings (i.e. worries)

Expectations:Expectations: determines the patient’s goals, determines the patient’s goals, what help the patient had expected for each what help the patient had expected for each problemproblem

Cues:Cues: picks up on verbal and non-verbal cues picks up on verbal and non-verbal cues (body language, speech facial expressions, (body language, speech facial expressions, affect); acknowledges and checks out as affect); acknowledges and checks out as appropriateappropriate

FIFEFIFE

FunctionFunction IdeasIdeas FeelingsFeelings ExpectationsExpectations

FIFEFIFE

FunctionFunction IdeasIdeas FeelingsFeelings ExpectationsExpectations

Patient’s presents problem

Gathering Information

Parallel search of two frameworks

Illness frameworkPatient’s agenda

ideasconcerns

expectationsfeelingsthoughtseffects

Understanding thePatient’s unique

Experience of illness

Integration of the 2 frameworks

Explanation and planning: shared understanding and decision-making

Disease frameworkDoctor’s agenda

symptomssigns

investigationsunderstanding pathology

Differential Diagnosis

Providing

Structure


preparation

establishing initial rapport

identifying the reason(s) for the consultation

providing the correct amount and type of information

aiding accurate recall and understanding

achieving a shared understanding: incorporating the patient’sillness framework

planning: shared decision making

Closing the Session

Building therelationship

••

•

••

•

•

•

•

•


Physical examination


making organisation overt

attending to flow

• exploration of the patient’s problems to discover the:

biomedical perspective the patient’s perspective

background information - context

• ensuring appropriate point of closure• forward planning

using appropriate non-verbal behaviour

developing rapport

involving the patient

•

•

AN EXAMPLE OF THE INTER-RELATIONSHIP BETWEEN CONTENT AND PROCESS

Gathering Information

Process Skills for Exploration of the Patient’s Problems patient’s narrative question style: open to closed cone attentive listening facilitative response picking up cues clarification time-framing internal summary appropriate use of language additional skills for understanding patient’s perspective

Content to Be Discovered

the bio-medical perspective (disease) the patient’s perspective (illness) sequence of events ideas and beliefs symptom analysis concerns relevant systems review expectations effects on life feelings

background information - context past medical history drug and allergy history family history personal and social history review of systems

Patient's Problem List

Exploration of Patient's Problems

Medical Perspective – disease Patient's Perspective - illness Sequence of events Ideas and beliefsSymptom analysis ConcernsRelevant systems review Expectations

Effects on lifeFeelings

Background Information - ContextPast Medical HistoryDrug and Allergy HistoryFamily HistoryPersonal and Social HistoryReview of Systems


Differential Diagnosis - HypothesesIncluding both disease and illness issues

Physician's Plan of ManagementInvestigations Treatment alternatives

Explanation and Planning with PatientWhat the patient has been toldPlan of action negotiated

Diagnosis of Abd PainDiagnosis of Abd Pain

What are possible causes of abd pain in this What are possible causes of abd pain in this patient?patient?

What is you number 1 candidate?What is you number 1 candidate? What would you expect to find on physical What would you expect to find on physical

exam?exam? What further diagnostic tests are indicated What further diagnostic tests are indicated

if any?if any? What would you tell the patient?What would you tell the patient? What are your treatment options?What are your treatment options? How would you treat this patient?How would you treat this patient?

Putting Clues TogetherPutting Clues Together

"Medicine is a science of uncertainty "Medicine is a science of uncertainty and an art of probability."and an art of probability."


Initial Clues/Initial Hunches

Inquiry Hypothesis Generation

Case Building

Hypothesis Evaluation

Diagnostic Decision

Therapeutic Decision

Hypothetico-deductive Hypothetico-deductive methodmethod

Differential diagnosis

EpidemiologyEpidemiology

Does this patient have any risk Does this patient have any risk factors to predispose to a cause of factors to predispose to a cause of abdominal pain?abdominal pain?

Describe the patient’s Describe the patient’s abdominal pain?abdominal pain?

Where is it located?Where is it located?

Differential DiagnosisDifferential Diagnosis

Location of painLocation of pain

Differential DiagnosisDifferential Diagnosis

Epigastric painEpigastric pain Peptic ulcer diseasePeptic ulcer disease Gastroesophageal reflex diseaseGastroesophageal reflex disease GastritisGastritis PancreatitisPancreatitis Myocardial infarctionMyocardial infarction Ruptured aortic aneurysmRuptured aortic aneurysm

Describe the patient’s Describe the patient’s abdominal pain?abdominal pain?

Location, radiationLocation, radiation QualityQuality SeveritySeverity Timing: onset, duration, frequencyTiming: onset, duration, frequency Setting or contextSetting or context Modifying factors: aggravating, Modifying factors: aggravating,

alleviatingalleviating Associated symptomsAssociated symptoms

Diagnosis Epidemiology Etiology Presentation Physical examination

Peptic ulcer

Occur in all age groups. Peak at age 50. Men affected twice as much as women. Severe bleeding or perforation in less than 1% of patients.

May be associated with Helicobacter pylori infection. Risk factors include COPD, NSAID use, tobacco and alcohol use.

Nonradiating epigastric pain that starts 1–3 hours after eating and is relieved by food or antacids. Pain frequently awakens patient at night.

Epigastric tenderness without rebound or guarding. Perforation or bleeding leads to more severe clinical findings

Pathophysiology of Peptic Pathophysiology of Peptic Ulcer DiseaseUlcer Disease

Is this the whole story of Is this the whole story of abdominal pain in this abdominal pain in this

patient?patient?

Describe this patient’s Describe this patient’s peptic ulcer disease peptic ulcer disease

“illness”“illness”

Make a Problem List for Make a Problem List for This PatientThis Patient

Make a Problem List for Make a Problem List for This PatientThis Patient

Peptic ulcer diseasePeptic ulcer disease StressStress DepressionDepression InsomniaInsomnia Back painBack pain SmokingSmoking Alcohol problemAlcohol problem

Other Aspects of Other Aspects of Encounters With This Encounters With This

PatientPatient DepressionDepression

DiagnosisDiagnosis TherapyTherapy

Office-based counselingOffice-based counseling MedicationsMedications RefferalRefferal

StressStress NegotiationNegotiation

Other Aspects of Other Aspects of Encounters With This Encounters With This

PatientPatient Rapport and trustRapport and trust EmpathyEmpathy Dealing with emotionsDealing with emotions Health behavior changeHealth behavior change

Smoking cessationSmoking cessation AlcoholAlcohol

Determine degree of problem: CAGEDetermine degree of problem: CAGE Alcohol counselingAlcohol counseling

Prevention and health promotionPrevention and health promotion

End of Case DiscussionEnd of Case Discussion

Questions?Questions? Comments?Comments?

Evolution of a Physician:Evolution of a Physician:How Do We Get There?How Do We Get There?

First-YearMedical Student

PracticingPhysician

Where You Are NowWhere You Are Now KnowledgeKnowledge SkillsSkills AttitudesAttitudes ExperiencesExperiences Personal developmentPersonal development

Where do you want to Where do you want to be?be?

Evolution of a Physician:Evolution of a Physician:How Do We Get There?How Do We Get There?

First-YearMedical Student

PracticingPhysician

Professional Development•Knowledge•Skills•Attitudes

Who are physicians Who are physicians accountable to?accountable to?

Who are physicians Who are physicians accountable to?accountable to?

PatientsPatients Other healthcare professionalsOther healthcare professionals CommunitiesCommunities Accreditation boards and medical Accreditation boards and medical

societies societies Healthcare systemHealthcare system Society in generalSociety in general Themselves and their familiesThemselves and their families

What do these stakeholders What do these stakeholders expect of physicians?expect of physicians?

That we are competentThat we are competent

Defining Professional CompetenceDefining Professional Competence

The habitual and judicious use of The habitual and judicious use of communication, knowledge, technical skills, communication, knowledge, technical skills, evidence-based decision-making, emotions, evidence-based decision-making, emotions, values and reflection to improve the health of values and reflection to improve the health of the individual patient and the communitythe individual patient and the community . .

Epstien

Most patients take our technical Most patients take our technical expertise for granted. expertise for granted.

What they evaluate, however, is the What they evaluate, however, is the art of the care, the human side of art of the care, the human side of how the care is delivered, and the how the care is delivered, and the compassion and concern for their compassion and concern for their welfare exhibited by physicians.welfare exhibited by physicians.

John J. Gartland, MD

What Patients Want

““Mastery of the broad spectrum of Mastery of the broad spectrum of knowledge, skills, and attitudes knowledge, skills, and attitudes necessary to accurately and necessary to accurately and compassionately perform our role compassionately perform our role defines what it means to be a defines what it means to be a physician and not just a technician.”physician and not just a technician.”

Trainer and Kirug

ACGME Competencies ACGME Competencies

Patient carePatient care Medical KnowledgeMedical Knowledge Interpersonal and communication Interpersonal and communication

skillsskills ProfessionalismProfessionalism Systems-based practiceSystems-based practice Practice-based learning and Practice-based learning and

improvementimprovement

Where You Want to BeWhere You Want to Be

Component in:Component in: Patient carePatient care Medical KnowledgeMedical Knowledge Interpersonal and communication skillsInterpersonal and communication skills ProfessionalismProfessionalism Systems-based practiceSystems-based practice Practice-based learning and Practice-based learning and

improvementimprovement

The Evolution of a Physician is The Evolution of a Physician is Never CompleteNever Complete

?

“ “The hardest conviction to get into The hardest conviction to get into

the mind of a beginner is that the the mind of a beginner is that the education upon which he is engaged education upon which he is engaged is not a college course, not a is not a college course, not a medical course, but a life course, for medical course, but a life course, for which the work of a few years under which the work of a few years under teachers is but a preparation.”teachers is but a preparation.”


QuestionsQuestions

What is the most powerful diagnostic What is the most powerful diagnostic and therapeutic tool in medicine?and therapeutic tool in medicine?

Healthcare ProfessionalsHealthcare Professionals

Healthcare ProfessionalsHealthcare Professionals

Teams are more effective than Teams are more effective than individualsindividuals

Must exhibit professionalismMust exhibit professionalism

QuestionsQuestions

What is the most crucial knowledge What is the most crucial knowledge one needs in medicine?one needs in medicine?

Self-KnowledgeSelf-Knowledge

Self-assessmentSelf-assessment What you know and what you don’t What you know and what you don’t

knowknow What you know about the way you make What you know about the way you make

decisions: moral reasoningdecisions: moral reasoning BiasesBiases

Life-long learning and improvementLife-long learning and improvement ReflectionReflection

QuestionsQuestions

What is the most important skill one What is the most important skill one needs in medicine?needs in medicine?

CommunicationCommunication

Communicating with patients and Communicating with patients and their families their families

Communicating about the patientCommunicating about the patient Oral and written communicationOral and written communication Team communicationTeam communication

Communicating about medicine and Communicating about medicine and sciencescience TeachingTeaching

QuestionsQuestions

What is the one most important What is the one most important attitude one needs in medicine?attitude one needs in medicine?

CaringCaring

““One of the essential qualities of the One of the essential qualities of the clinician is interest in humanity, for clinician is interest in humanity, for the secret in the care of the patient the secret in the care of the patient is caring for the patient.”is caring for the patient.”

Francis W. Peabody, MD. JAMA, March 19, 1927Francis W. Peabody, MD. JAMA, March 19, 1927

Documents

Discussion of SP Case. Agenda Discussion of SP case Discussion of SP case Review key principles of clinical medicine Review key principles of clinical