Doctor Patient Communication Rounds
Working with Patients from Different Cultures
Working with Difficult Patients
Caring for Patients at the End of Life
Goal: Students will be able to identify patients at risk for alcohol related problems and employ effective interventions for behavioral change.
Objectives: Students will be able to:
1) Identify problem drinkers.
2) Stratify drinkers along continuum of risk.
3) Develop strategies for working with problem drinkers that integrate the principles of motivational interviewing and The Prochaska Model of change.
4) Utilize the Ask - Assess - Advise/Assist - Monitor model in working with patients at risk for alcohol related problems.
The focus for this session is the development of interviewing skills that will enable students to work effectively with patients at risk for alcohol related problems.The session is based closely on the handout Alcohol and Substance Abuse: Physician Skills. Please read the handout before the session.
1) Patients who drink alcohol can be risk stratified using the following criteria:
A) Low Risk Use:
B) Hazardous Use: Drinking beyond the above mentioned limits but without harmful consequences.
C) Harmful Use: Evidence of impaired physical, emotional, social or spiritual health. (e.g. elevated GGT or MCV, gastritis, hepatitis, difficulties at work, impaired social function, financial problems, DUI conviction, etc.)
D) Alcohol Dependence: Evidence of tolerance and/or symptoms of withdrawal.
2) Students can effectively and efficiently screen for problem drinkers using the following questions:
A) Has alcohol ever caused a problem for you or your family?
B) Ask CAGE questions: cut down, annoyed, guilty, eye opener.
C) How many drinks do you usually have on the days you drink?
D) What was the maximum number of drinks per occasion in the past month.
Patients are deemed to be at risk when a & b are positive and/or NIAAA guidelines listed in #1 are exceeded.
3) All patients found to be at risk should receive further assessment in order to:
A) Clarify degree of risk
B) Assess patient's readiness for change.
C) Elicit patient's perspective on the pro's and con's of continued drinking vs. the pro's and con's of stopping.
4) Upon completing the assessment, students should:
A) Provide the patient with feed back about his/her drinking patterns and the risks/benefits discussed in the assessment, wherever possible using the patients own words.
B) Assist the patient in developing a plan of action that is consistent with his/her readiness to change.
Objectives: Students will be able to:
1) Describe how culture influences health behaviors and outcomes.
2) Develop strategies for establishing rapport with patients despite language / cultural barriers.
3) Elicit patient's explanatory model of his / her illness.
4) Negotiate with patient (when doctor and patient's explanatory models do not coincide) to arrive at a mutually agreed upon plan of action in reference to diagnostic testing, treatment, adherence, etc.
This model is based closely on the article: Cross-Cultural Primary Care: A Patient Based Approach by Carrillo et.al.
During the clinical years, students frequently work with patients who differ from them in terms of ethnicity, socio-economic status, educational level, religion, and country of origin. These differences often create a cultural divide that students find difficult to breach. The goal of this session is to make students more aware of how cultural differences impact on the doctor patient relationship and subsequent health outcomes and to provide them with skills to work with patients from diverse cultural and socio-economic backgrounds.
1) Elicit students' experiences of working with patients from different cultures.
2) Define culture broadly (i.e. "shared system of values, beliefs, and learned behaviors") that is not necessarily defined by ethnicity or country of origin (e.g. "housestaff culture". "IVDA Culture.") Culture is influenced by a multiplicity of variables including age, socio-economic status, gender, sexual orientation, and degree of acculturation to mainstream society, etc.
3) Avoid focusing on beliefs / behaviors of particular ethnic groups. This approach tends to limit rather than broaden the students' perspective and often leads to negative stereotyping.
4) Focus on the skills that can be used with all patients regardless of their particular backgrounds, i.e.
A) Heightened awareness of "core issues" where culture is highly influential e.g. role of family, physical contact, relationship to authority. (See module 2: Carrillo Article) When such issues arise they should be explored and clarified.
B) Elicitation of patient's explanatory model. (see Kleinman questions Table 12.3 Cultural Factors in the Medical Interview)
C) Negotiation of
differences between the doctor and patient's explanatory models. This
can be achieved through:
Goals: Students will be able to identify and effectively work with patients with different personality styles.
Objectives: Students will be able to:
1) Recognize the presentation of common personality styles.
2) Understand how a patient's personality style can influence diagnosis and treatment.
3) Begin to develop strategies for working with patients with particular personality styles.
4) Recognize personal feelings elicited by difficult patients.
By the end of the session, students should be able to recognize that difficult patients are often exhibiting deeply ingrained patterns of behavior (personality styles) that are frequently exacerbated in times of illness or stress.
Recognition and understanding of these personality styles can enable students to act constructively and therapeutically, rather than to react emotionally in ways that contribute to conflictive, non-productive interactions.
The focus of this
session should be:
If time permits-additional
personality styles can be discussed.
Goal: Students will
demonstrate an understanding of the physician's role in end of life
Students will be able to:
1) Elicit patient's understanding of disease process / prognosis.
2) Assess patient's desire to know details of disease process / prognosis.
3) Elicit patient's goals / concerns at end of life.
4) Identify resources / treatment available to help address patient's goals and concerns.
5) Recognize and reflect on their own feelings.
1) Spend some time initially exploring students' concerns about working with terminally ill patients (e.g. fear, sadness, unfamiliarity with death, lack of knowledge, uncertainty about their roles, sense of impotence, etc.).
2) Discussion of "Essential Domains of Quality of Life in End of Life Care" should allow students to arrive at clear understanding of physicians' role in end of life care. Focus on paradigm shift from care to palliation, and on enhancement of patient autonomy. Review resources available to students (e.g. social workers, pastoral care, hospice care, etc.).
3) Explore components
of the patient interview at the End of Life. Focus should be less on bio-medical
aspects of care and move on development of communication skills.
Clinical Reasoning Rounds
1) Intro interactive
lecture/seminar by MS.
2) Clinical Reasoning
Rounds at bedside, 2 One hour sessions.
Kassirer, J, Kopelman, R. Learning Clinical Reasoning. Chapters 1,2 &3 and glossary. Williams & Wilkins
Kaplan,C. Hypothesis Testing. Pgs.20-30
Teaching Clinical Medicine by Iterative Hypothesis Testing. New England Journal of Medicine, V.309: 921-923, 1983.
Initiative on Health Communication
Division of Primary Care
NYU School of Medicine
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