Transcript 48x72 poster template - American Association of Colleges

Simulation Exercises to augment new Residency Training Program in Family Medicine
AF Clowers, DO, MG Herring, MD, FJ Humphrey, DO, LB Weiss, MS, SC Bennett, MPH RD, FA Filipetto DO
School of Osteopathic Medicine, Department of Family Medicine , University of Medicine and Dentistry of New Jersey
AIM
This poster describes the use of
Standardized Patient encounters to
augment a Resident Family Medicine
training program addressing Mental
Health, Cultural Competence and End-ofLife Palliative Care.
METHOD
Nine, 30-minute, Standardized
Patient (SP) scenarios were
developed as part of the
integration of new curricula for
Family Medicine residents
focusing on mental health,
cultural competence and
palliative end-of-life care.
Residents received Web-CT
instruction in these areas
correlating with both formative
and summative SP cases.
Checklists identifying 25
competencies were developed
focusing on history and
diagnostic acumen,
psychosocial and cultural
issues, community resources
and interdisciplinary care, as
well as treatment and case
management.
Mental Health Cases
Cultural Competence Cases
Palliative end-of-life Cases
-- Case 1 – Forgetfulness --
-- Case 1 – Productive Cough --
-- Case 1 – Truth Telling in a Terminal Diagnosis –
The patient is a former patient of your practice.
Three years ago she moved to a retirement
community with her husband and switched
providers because of travel distance. You had
heard through the community that the patient’s
husband had died about 1 ½ years ago. Your
last contact with her was when you sent a
condolence card. As a favor to the patient’s very
concerned daughter, Joan, also a patient of
yours, you have agreed to see her. The chart is
in storage and could not be retrieved for this
visit.
Patient is a 16 year old Cambodian male who is
new to your office. He presents with five days of
fever, chills, dizziness, fatigue and productive
cough. The patient is a first-generation citizen in
this country, who lives with his mother, father, and
two brothers. He attends a local high school.
You are the attending physician for Lloyd Jones, a
65 year old man whose needle biopsy today
revealed inoperable cancer. Your resident has
already spoken to the daughter, Gwen Jones, and
told her of her father’s poor prognosis with and
without treatment. Ms. Jones has requested to
see you ASAP, and you’ve heard that she is
insisting that no one tell her father about his
diagnosis. You are about to see her in a small
hospital conference room to address her concerns.
Learner Task: Examination of patient reveals
petechiae and ecchymosis on posterior chest
consistent with the traditional practice of cao gio
(coining), but which might be confused with
remnants of abusive treatment to the uninformed
observer. Learner is expected to identify cultural
practices and incorporate them into treatment plan.
Learner Task: After performing a complete
history, Mental Status Exam, Mini Mental Exam,
and physical, the learner is expected to
diagnosis and discuss various causes of
memory loss including dementia and major
depression.
Case 2 – Fatigue and Dysmenorrhea –
You are seeing the patients of a colleague away on
a family emergency including a follow-up visit with
this 40 year old patient, a Jehovah's Witness, who
is here today to review her blood work and pelvic
ultrasound that a GYN doctor had ordered. A copy
of these test, as well as the GYN opinion has been
sent to you. The patient is looking for your input.
Recently ordered blood work reveals anemia. A
recently ordered pelvic ultrasound reveals uterine
fibroids.
-- Case 2 – Headache -You are a physician working in primary care.
The daughter of one of your patients comes to
be seen to have her headaches evaluated. The
patient is new to you.
There is no prior
relationship and no prior chart.
Learner Task: Diagnose one of the most
common mental illnesses seen in primary care,
anxiety disorder. Recognize how anxiety
disorders are often seen in combination with
other disorders especially mood disorders.
Learner Task: Patient is looking to the learner for
input given the conflict between her medical needs,
the strong recommendation of her GYN and her
religious practices. Learner is expected to identify
religious practices and beliefs and incorporate
available alternative therapies into the care of this
patient.
-- Case 3 – Restlessness –
You are a physician working in a primary care
office in a community with psychiatrists
scattered few and far between. One of your
patients seeks you out to provide care for her
mentally ill son, who seems to be having an
exacerbation of his primary recurrent symptoms.
The patient is new to you, however, his mother,
Mary Russell, has been a patient of yours for
several years. The patient has recently been
discharged from the area Hospital for the
Mentally Ill and you were soon to become his
primary care provider.
However, the
appointment has been moved up because of
escalating symptoms that are worrisome to the
mother and very disturbing to the son (the
patient). The patient’s medical records have not
yet been received from his hospitalization.
-- Case 3 – Caretaker Malaise -You are the primary care physician for your patient,
Gracia Morales, a 50 year old Hispanic patient in
your care for over 10 years. Your patient’s husband,
also a patient of yours, was diagnosed two years
ago with colon cancer. Three weeks ago, after not
seeing Ms. Morales for a while, you saw her for
various non-specific complaints – aches, pains,
fatigue, insomnia – as well as gastrointestinal
distress (diarrhea, cramping). Your physical exam
at the time, and the tests you subsequently ordered,
revealed no physiological explanation for the
complaints. Ms. Morales is back for a follow-up visit
to discuss your findings and receive your counsel.
Learner Task: Upon questioning it is revealed that
Ms. Morales is caring for her terminally-ill husband
and she is very depressed. The learner is expected
to identify cultural variations of disease presentation
such as depression.
Learner Task: Perform a complete history,
physical, and mental status examination on this
patient who presents with anxiety, depression,
and restlessness. The learner is expected to
arrive at a diagnosis of Schizophrenia (Axis I)
and Akathisia (Axis III) and discuss an
appropriate treatment plan.
RESULTS
Learner Task: The learner is expected to discuss
with the family the concepts of truth telling and
address family fears and concerns regarding the
right to know.
-- Case 2 – Challenging Request in a Terminal
Diagnosis –
You are a family physician about to see your
patient of 5 years, Mr. Carl Wagner. You last saw
him 6 months ago when he came in complaining of
a chronic cough. A chest x-ray revealed a large
apical tumor, which turned out to be squamous cell
lung cancer. The tumor is not respectable, and he
has exhausted all treatment options. He has been
referred back by his oncologist for treatment to
keep him comfortable. He told the nurse he has
increasing pain, which is keeping him up at night.
He asks you for a three-month prescription of pain
medication.
Learner Task: The learner is expected to address
the patient’s fears at end of life which include being
a burden to his family, remaining autonomous, and
issues of dignity. Learner is expected to introduce
and explain the role of hospice and arrive at an
understanding that his fears and needs would be
attended to while addressing his request for
euthanasia.
Case 3 – Congestive Heart Failure -Mr. Shorter, a patient of yours for many years, is
suffering from end-stage Congestive Heart Failure,
secondary to long-standing ischemic
cardiomyopathy. Severe life threatening
thrombocytopenia from Heparin has impacted
negatively on any other surgical interventions. He
suddenly acutely worsened 8 weeks ago. He is in
his 5th hospitalization in the past 2 months.
Learner Task: The learner is expected to present
bad news in an empathic manner, recommend
hospice level care as a positive next step, and to
assure the patient of non-abandonment and total
dedication to his needs as he approaches his end
of life.
DISCUSSION
% Competencies
Case
Achieved
Mental Health (OGMI)
{ Headache
{ Forgetfulness
Formative
Formative
Case
Case
Summative
Case
{ Restlessness
62%
82%
83%
Cultural Competence (OGMII)
{ Productive Cough
Formative { Fatigue& Dysmenorrhea
Formative
Case
50%
93%
Case
Summative
Case
{ Caretaker Malaise
Analysis to be completed
Palliative Care (OGMIII)
{ Challenging Request
Formative { Truth Telling
Formative
Case
82%
85%
Case
Summative
Case
{ Heart Failure
94%
Simulation exercises with formative feedback
and evaluation can be very effective for
residents to improve and refine their
interpersonal and communication skills in
managing palliative, mental health and
culturally sensitive patient needs. Residents’
performance improved as a result of the 2
formative standardized cases where residents
are evaluated and given feedback regarding
the competencies identified. The summative
case had the highest scores in competency
achievement in the areas of mental health and
palliative care.