Transcript Incorporating Diagnostic Reasoning into your Teaching

Medical Student Role on
Family Centered Rounds (FCR)
Part 1:
How to Succeed
Mary Ottolini MD, MPH
Vice Chair of Medical Education
Overall Objectives For Successful
Presentations During FCR:
Part 1 Objectives
•
Describe the purpose of FCR and your role.
1. Use the ‘PBEAR’ format to give easy to follow, succinct oral presentations
•
including only pertinent positive and negative findings
Part 2 Objectives (discussed in separate presentation)
1. Begin a presentation on a new patient by representing the “Big Picture”
(Problem Representation)
+
=
Identify the ‘defining features’
Use adjectives (‘semantic qualifiers’) to describe how you’re thinking
Combine into a ‘Problem Representation’
Part 3 Objectives (discussed in separate presentation)
1. To use discriminating features to analyze the differential diagnosis
2. Describe the difference in the presentation for a new vs. an old pt
Part 1 Objectives
1.
Describe the purpose of FCR and your role.
2.
Use the ‘PBEAR’ format to give easy to follow, succinct
oral presentations
•
including only pertinent positive and negative findings
What is the purpose of FCR?
Please click on the video below to play:
Play Video
The Purpose of Rounds
1. Calibrate and Correct a Shared Mental Model
2. Create a Plan for the Day
3. Assign and Accomplish Tasks
4. Plan Transitions of Care
5. Educate Yourself and the Patient/Family
1. Calibrate and Correct a Shared
Mental Model
Use (I) PBEAR (SS)
• (I) Introductions and greeting
–
–
•
PBEAR
–
–
•
Use this structure for your case presentation
Communicate a clear thought process
(S)olicit relevant input from staff/team members–
•
Senior resident says hello- introduces team
Asks parent/patient what concerns them most today and why?
Senior Resident asks Nurse, Case Manager, patient and parents
(S)hare the team’s mental model with the family
–
–
Senior Resident Checks understanding
Asks about data that doesn’t fit
2. Create a Plan for the Day
•
Based upon pertinent data (meds, studies, VS, overnight events)
•
Assess progress and Anticipate likely problems
•
Propose a Plan
•
Validate and Verify the plan
– Team members
– Parents/patients
3. Assign and Accomplish Tasks
•
Renew, refine or discontinue patient orders
•
Jot down tasks to complete after rounds
4. Plan Transitions of Care
•
Assess discharge/transfer criteria
– Estimate the Timeline
•
Identify specific transition needs
– (wean O2, family teaching, referral to rehab)
5. Educate Yourself and the Family
•
Just-in-time and self directed learning:
– Identify your gaps
– Write down questions
– Use your smart phone
to look up information
– Observe the Physical Exam
•
Family integration and education:
– Address concerns and confirm comprehension
Learning During Family Centered Rounds
What makes it work?
Efficient Case Presentations
Don’t Repeat
See/Examine the Patient
Deliberately Multi-task:
Look up information about the pt during rounds
Efficient Presentations are
Crucial to Your Learning!!
Succinct, Clear Presentations
Changing the emphasis from:
Data delivery -------- Data synthesis
Thoroughness-------- Selectivity
All the data ------ The pivotal data
“Hx-heavy” ----------- “DDx-heavy”
Traditional Case Presentation
vs. PBEAR
•
CHIEF COMPLAINT
•
P: PROBLEM
– Represent the problem using adjectives to
communicate how you are thinking about
the defining features of the problem
•
•
HISTORY, PE; LAB
•
ASSESSMENT
•
PLAN
B: BACKGROUND EVIDENCE
– Report ONLY the key evidence relating
to the Dx/Rx of problem
– Ask if more data is needed
•
A: ANALYSIS
– Analyze the differentialCompare/contrast discriminating
features/evidence to determine diagnosis
•
R: RECOMMENDATION
–
–
–
–
Express uncertainty
Goals for management
The Plan
State what you are going to read about
Communication Skills:
• Speak audibly/ clearly
• Avoid Digressing or Repeating
• Avoid Intermixing data where it doesn’t belong
(i.e. PE findings during HPI)
• Use medical terms appropriately.
• Use notes appropriately
• Look parents in the eye-Be Sensitive to impact
Background Evidence:
• Background Evidence: Subjective (History)
– Accurately synthesize the history
• Problem-focused with pertinent positives/ negatives.
• Omit Irrelevant Data
– Logical progression of events- easy to follow
• Background Evidence: Objective Data:
– Accurately synthesize the physical exam and lab data.
• Include problem-focused pertinent positives/ negatives and
pending data
• Omit Irrelevant Data
.
Watch the Video and Assess:
1. Communication
2. Background Evidence
Please click on the video below to play:
Play Video
Communication Skills:
•
•
•
•
Speaks audibly/ clearly
Uses medical terms appropriately.
Uses notes appropriately
Sensitive to impact on patient/ family.
X
Spoke inaudibly or unintelligible
«------------------------------------------------------------»
Often digressed/ repeated.
«------------------------------------------------------------»
No repetition/ digression
Read or used notes inappropriately.
«------------------------------------------------------------»
Used notes completely appropriately.
Ignored patient/ family.
«------------------------------------------------------------»
Intermixed data (ie history in PE)
«------------------------------------------------------------»
X
X
NA
X
Spoke completely clearly and audibly.
Clearly Included patient/ family.
Presented all data in the correct category
His speech was audible, but with a lot of “uhms”
Notes should only be referred to for discrete data points- not read
“Mom said she looked sick…No travel outside the country”-this is out of order/confusing
Background Evidence:
Background Evidence: Subjective (History)
• Accurately synthesizes admitting/ interim history.
• Problem-focused with pertinent positives/ negatives.
• Logical progression of events.
Omitted most of the relevant data
Included irrelevant data.
Confusing progression of events.
X
«------------------------------------------------------------»
«------------------------------------------------------------»
«------------------------------------------------------------»
X
X
Included ALL the relevant data.
Omitted ALL the irrelevant data
Easy to follow progression of events.
The cough should be described in more detail and in the HPI not ROS.
The
amount of intake and urine output should be described in greater detail
•
to assess hydration.
Developmental Hx and Family History are irrelevant to the presenting problem
“NSVD- was discharged in 3 days…mother was unsure of GBS status”this is irrelevant and confusing
Background Evidence: Objective
Data:
X
«------------------------------------------------------»
Omitted most of the relevant
data
X
Included ALL the relevant data
Included irrelevant data
«------------------------------------------------------»
Omitted ALL the irrelevant data
Exam/ labs inaccurate/incorrect
«----------------------- ------------------------------»
X
Accurate/correct exam/ lab data
Comments:
No description of her overall appearance; no vital signs, inadequate pulmonary exam
Normal eye findings are irrelevant; get an Otoscope!
Don’t state details of normal and irrelevant lab values- ie U/A and Lytes
In Summary…
Be prepared to discuss the following questions:
1. Describe the 5 purposes of Family Centered Rounds?
2. Explain PBEAR format for presenting.
3. What are the key attributes of good Communication?
4. How do you determine what Background Evidence is
pertinent to present on FCR?