Internal Medicine

Format
Students will participate in 2 separate activities during their Internal Medicine Clerkship.

• Doctor Patient Communication Rounds
  Each week a faculty member will meet with students and interview a patient on the Bellevue Wards. These sessions will take place only while students rotate on the Bellevue Wards (each 5 week block). The interviews will reinforce Core Communication Skills as well as focus, when relevant, on the Topics listed below. Students will be responsible for finding appropriate patients. The interviews will be followed by a debriefing session.
• Clinical Reasoning Rounds
  There will be 3 sessions during the 10 week block (all students expected to attend each session). The first session will be an interactive lecture reviewing the vocabulary, principles, and concepts of diagnostic reasoning. The last 2 sessions will take place in smaller groups at the bedside and allow students to observe and practice how physicians use interviewing skills to make a diagnosis. These sessions will be held during the 4PM Core Conference Times.

Doctor Patient Communication Rounds

Core Communication Skills
Goal: Students will have a chance to practice, be directly observed and receive feedback about core communication skills.

Asking Patients about Alcohol Problems
Goal: Students will be able to identify patients at risk for alcohol related problems and employ effective interventions for behavioral change.

Working with Patients from Different Cultures
Goal: Improve cross-cultural communication between doctor and patient.

Working with Difficult Patients
Goal: Students will be able to identify and effectively work with patients with different personality styles.

Caring for Patients at the End of Life
Goal: Students will demonstrate an understanding of the physician's role in end of life care and will improve their ability to communicate with terminally ill patients.

Facilitator Handout
Session #1: Patients with Alcohol Problems

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.

Teaching Points

1) Patients who drink alcohol can be risk stratified using the following criteria:

A) Low Risk Use:
Men younger than 65: 14 or fewer drinks per week. Not more than 4 drinks at a time.Women and men over 65: 7 or fewer drinks per week. Not more than 3 drinks at a time.

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.

5) Interviewing skills to be addressed:
- open-ended questioning
- non-judgmental, empathic listening
- reflection of patient's own words
- summarizing of perceived pro's and con's (elements of ambivalence) to help patient uncover the dissonance between perceived self-interest and on-going drinking behavior
- affirmation of patient's autonomy and self-efficacy
- promotion of partnership

Session #2 Working with Patients from Different Cultures

Goal: Improve cross-cultural communication between doctor and patient.

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.

Teaching Tips

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:
- explicitly stating both models
- trying to arrive at common goals e.g. alleviation of pain
- exploring options
- re-framing diagnostic/treatment plan in terms that
are consistent with patient's health benefits
- prioritizing and compromising

Session #3 Difficult Patients

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.

Teaching Points
Students often perceive difficult patients as being intentionally obstructive or antagonistic. These patients tend to elicit strong negative emotions in students, which can interfere with their ability to function as effective clinicians.

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:
1) identifying the personality style of the difficult patient presented by the student
2) developing strategies for working with patients who exhibit that personality style (see handout)
3) helping students to recognize their emotional reactions and to use these reactions as diagnostic data in identifying particular personality styles

If time permits-additional personality styles can be discussed.
The article on personality styles is provided as a reference for facilitators. Students are expected to read the introduction, conclusion, and table 21.

Session #4 Caring For Patients at the End of Life

Goal: Students will demonstrate an understanding of the physician's role in end of life
care and will improve their ability to communicate with terminally ill patients.

Objectives:

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.

Teaching Points

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.
- elicitation of patient's goals / concerns
- conveying support, empathy, acceptance
- viewing patient as whole person
- enhancing patient autonomy
- promoting partnership

Clinical Reasoning Rounds

Faculty Instructions:

1) Intro interactive lecture/seminar by MS.
a) Review vocabulary, principles, and concepts of Dx reasoning, cognitive psychology, etc.
b) Learn via interactive exercises and cases
c) Prepare students for 2nd session

2) Clinical Reasoning Rounds at bedside, 2 One hour sessions.
a) Select 1-2 patients on ward who
i) Present Dx challenge either because:
(1) Complex with multiple Dx hypotheses
(2) Vague or confusing presentation making it hard to generate Dx hypos
ii) Speak English and seem cooperative with sense of humor!
b) One student ("expert") who knows the patient and comes prepared with chart or summary of data
c) Iterative bedside interview of patient by another student ("interviewer") in "chunks" (clinically meaningful, chronological collections of data)
i) Frequent process breaks (at bedside or in hall?)
(1) Other students "think out loud" about Dx hypos
(2) Facilitator
(a) keeps group on track
(b) highlights Dx reasoning process
(c) reviews concepts, strategies, heuristics
(d) encourages students to estimate probabilities of major hypos
(e) highlights interviewing skills and helps group guide the interviewer
(3) Use flip chart at bedside to track hypos
ii) Keep returning to patient or student expert for new data in response to questions driven by the Dx hypos
iii) Continue process until group is satisfied they have a "differential diagnosis" (set of surviving, competing Dx hypos)
iv) Make best estimate of "working diagnosis" based on its
(1) Adequacy - sufficiency - accounts for all findings
(2) Coherence - all findings, risk factors, etc are consistent with pathophysiology and causality of hypothesized disease
v) Reach closure of case by
(1) Revealing confirmatory/refutational Dx test data
(2) Terminating interview with patient by
(a) checking his/her understanding of "working diagnosis"
(b) asking if pt has questions
(c) ask pt for feedback on experience
(3) Recap learning points

Readings:

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.

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