Profession

Professionalism and Strategies for Achieving Excellence 

• occupation that utilizes a special body of knowledge while competing for economic, social, and political rewards
• Standards of education and practice
• Professional associations
• Social contract in which professional is granted autonomy in exchange for meeting expected responsibilities
• No ethical or moral value

Medical Profession

Professionalism and Strategies for Achieving Excellence

• Specialty that requires long and demanding training
• Privilege to do things most people do not
• Years of training,apprenticeship, and continuing education
• Autonomy in decision making as part of social contract

Hippocratic Oath 

Professionalism and Strategies for Achieving Excellence

• Greek physician Hippocrates (460-380BC) wrote oath as guideline for medicthe ethics
• Staff of Asclepius used assymbol sinceI represented god of healing, and Hippocrates may have been member of guild of Asclepiad 
• Oath still holds valid in modern times because it was the first distinction ever made between curing and killing, as 'we are to be committed to life under all circumstances'

The Lun Dayi Jingcheng

Professionalism and Strategies for Achieving Excellence

• Sun Simiao (581-682) wrote of the importance of a calm mind and compassion when practicing medicine to all without discrimination

'Medical Ethics'

Professionalism and Strategies for Achieving Excellence

• Dr. Thomas Percival wrote this in 1803
• It was not well perceived because it seemed that a code of conduct was not necessary and only those with indecenuse used it to pretend they had a moral standard

AMA Code of Ethics 

Professionalism and Strategies for Achieving Excellence

• Written in 1847
• First national code for professionalism and medical ethics heavily drawn from Percival'srewriting
• Code is for a collective group of people whereas an oath is for personal duty

Changes in Medicine

Professionalism and Strategies for Achieving Excellence

• More closesly connected to application of expert knowledge and less to functions central to good of public
• Rise in expert professionalism and decline in social trustee professionalism

Systemic Challienges to Medical Professionalism

Professionalism and Strategies for Achieving Excellence

Health care delivery systems

• With multiple health care providers there is a possibility of insufficient collaboration/coordination/communication, fragmented care, and erosion of relationships between patients and doctors

Technology

• Although brings state-of-the-art medical care, shifts focus from patient to machine, causes over-reliance on techonology at expense of building a relationship, and does not allow for proper cost-containment

Reimbursement systems 

• Third-party payers cause third-wheel in the relationship, financial conflicts of interest, and commercialization of medicine

The Physician Charter

Professionalism and Strategies for Achieving Excellence

• Written by physicians in US and Europe in 2002 in response to changes in health care delivery systems that were felt to threaten the nature and values of medical professionalism

3 Fundamental Principles of Physician Charter

Professionalism and Strategies for Achieving Excellence

Set of Commitments of the Physician Charter

Professionalism and Strategies for Achieving Excellence

• Being professionally competent
• Improving quality of care
• Improving access to care
• Scientific  knowledge
• Maintaining trust by managing conflicts of interest
• Commiting to professional responsibilities
• Having appropriate patient relationships
• Keeping patient confidentiality
• Being honest with patients/having core humanisitic values

AAMC Medical School Objectives

Professionalism and Strategies for Achieving Excellence

• Altruistic
• Knowledgeable
• Skillful
• Dutiful

ACGME Post-MD Training Objectives

Professionalism and Strategies for Achieving Excellence

 Competency in...

• Patient care
• Professionalism
• Interpersonal skills and communication
• Medical knowledge
• Practice-based learning and improvement
• Systems-based practice

Communicating Professionalism as Medical Students

Professionalism and Strategies for Achieving Excellence

Show

• Attentiveness (non-verbal i.e. eye contact, mirroring, open posture, leveled position and verbal i.e. continuers, reflection)
• Empathy (non-verbal i.e. silence, pat and verbal i.e. identifying emotion, reflection emotion, legitimation)
• Respect (non-verbal i.e. punctuality, dress code, confidentiality and verbal i.e. positive feedback)
• Support
• Shared-decision making/partnership

Objectives:

Professionalism and Strategies for Achieving Excellence

• Define fundamental principles of medical professionalism
• Identify tangible expressions of medical professionalism
• Discuss how to communicate attentiveness, empathy, respect, support, and partnership
• Reflect on potential barriers to professionalism
• Begin to recognize strategies for making professionalism robust to challenges

Ideals for Professionalism in Patient-Physician Relationship

The Patient-Doctor Relationship

Punctuality

• Respect patient's time as much as you would like the patient to respect yours, time management, apologize if late

Confidentiality

• Be certain conversations cannot be overheard, inform patient about your confidentiality, remember that charts are seen by others

Attentiveness

• Be proactive with eye contact and positive body language

Mutual Respect

• Respect patient's decision even when it differs from your recommendation

Establish comfort and trust

• Office and staff are an extension of you, keep all conversations and medical records confidential, allow for comfort in the exam room before patient in gown

Honesty

• Do not make guarantees of outcomes, consistency, timeliness with return of phone calls/tests, explain your plan clearly

Shared-decision making

• Clearly explain all facts with benefits and risks for all treatment plans, must be in terms patient can understand, ask if patient wants anyone else present, allow time for questions, respect the final decision of the patient
• Shared-decision making shows respect for patient when they may have different value system, unburdens physician, allows physician to share all uncertainties

Appropriate level of communication

• Take level of education into account and do not insult patient, ask for their explanation back

• Values and beliefs
• Sensitivity
• Trust
• Confidentiality (i.e. INS)

Objectives:

The Patient-Doctor Relationship

• Describe key components of ideal patient-doctor relationship
• Reflect on relationship's basic code of conduct with respect to specific components of professionalism: punctuality, confidentiality, attentiveness, respect, and trust
• Appreciate importance of honesty, shared-decision making, communication skills, and cultural competency in establishing strong relationship
• Discuss basic strategies for communicating attentiveness, empathy, respect, partnership, and support

Society's Expectations

Professional Code

Altruistic

• Compassionate and empathetic, respect for patients' privacy and dignity, honest and non-judgemental

Knowledgeable

• Commitment to life-long learning

Skillful

• HPI, physical exam, diagnostic and therapeutic skills, communication

Dutiful

• promoting, maintaining, and improving health of individuals and populations

Personal Challenges to Professionalism

 Professional Code

• Fatigue/stress
• Fear of failure
• Lack of self-awareness
• Hidden curriculum
• Knowledge and skills set limitations

Systems-Based Challenges to Professionalism

Professional Code

• Physician reimbursement systems
• Health care delivery systems
• Tecnology

Characteristics of Accessiblity to Care

 Barriers to Access to Care

Accessible

Continuous

• Same provider throughout, assistance with transitions to different provider/ped to adult/in to outpatient

Comprehensive

• 24/7, preventive/primary/tertiaty care needs addressed, medical/educational/psychosocial needs addressed, information about private insurance and public resources given, extra time scheduled for special needs, advocating for patient needs 

Patient/family centered

• Provider known to family, mutual responsibility and trust, autonomy of patient and shared-decision making

Coordinated

• Care plan shared with involved providers/agencies/organizations, central medical record or database, information shared all along the way with patient, links to support groups and resources, evaluation and interpretation of consultant recommendations

Compassionate

• Concern for well being of patient and efforts are made to understand and empathize

Culturally effective

• Patient's cultural background valued, respected, and incorporated into care plan, translators if needed, written materials in primary language 

Nondiscriminatory

Barriers to Health Care

 Barriers to Access to Care 

• Lack of health insurance (mostly S states, 15.5% total, 12.5% children, lower incomes, young adults, disproportionately minority, less education, working)
• Lack of knowledge about resources
• Underinsurance (Growing at higher income levels, mental health access limited, dental care limited due to higher premiums and greater deductibles)
• Health reform law
• Lack of providers
• Transportation
• Language/cultural barriers

Children's Health Insurance Program

 Barriers to Access to Care

• Implemented in 1997 to make funds available for states to provide insurance for children, but many not know about the program
• Uninsured children decreased by 1/3, increased medicaid enrollment, more immunizations and improved health outcomes

Mental Health Parity and Addiction Equity Act of 2008

 Barriers to Access to Care

• Deductibles, co-payments, number of visits, out of network coverage must be similar to other medical benefits and out of network coverage
• Benefits for substance abuse
• Only for MH/SUD benefit packages

Patient Protection and Affordable Care Act

 Barriers to Access to Care

• Expand access (reduce exclusions with pre-existing conditions or annual limits, eliminate co-pay, medicaid=medicare payments, incentives for rural health care providers)
• Improve affordability of health insurance (individual and business tax credits, expansion of coverage)
• Improve quality of care (increase medicare drug coverage, systems for transitioning care, EMR, payment related to outcome)
• Changes in insurance company system (limit of profits)

2012 (Medicare cost controls, random [Indian health service, menu labeling, breastfeeding, prevention fund, screening], insurance reform [young adults on parents' plan, no lifetime limits]), 2014 (Medicaid to everyong 133% under poverty limit, more insurance reform, exchanges and tax credits), future (doctors paid based on quality of care) 

Major physician shortage with such an aging population of retiring older physicians and 32 million newly covered patients to be seen, especially in primary/dental/mental health care.

Objectives:

 Barriers to Access to Care

• Describe some of the many factors related to access to health care
• Emphasize the prevalence of barriers to health care access
• Introduce how limited access can lead to disparities in health care
• Introduce the Affordable Care Act and its impact on accessing care

National Health System

Introduction to the Health Care Systems in US

• Cuba, Great Britain
• Centralized, single-payer health system
• Universal coverage
• Government funded with all government facilities and employees

Universal Individual Health Insurance Systems

Introduction to the Health Care Systems in US

• Continental Europe, Japan, Latin America, Massachusetts
• Individuals own health insurance plan
• Employers and employees both contribute to plan (sickness funds [France and Germany])
• Facilities and practitioners private
• Government can regulate reimbursement rates

National Health Insurance System

Introduction to the Health Care Systems in US

• Canada
• Government run health insurance plan with tax revenue/public budget
• Government funded universal health care system
• Most services provided by private sector
• No copayments and other patient charges

US Health Care System

Introduction to the Health Care Systems in US

• Employed: universal individual health insurance
• Veterans health administration: national health system
• Medicare: national health insurance
• Unemployed, low-income: out-of-pocket
• Total health expenditure of $2.5 trillion projected to reach $4.6 trillion by 2019 (hospital care>physician/clinical>nursing care/continuing care>personal care>dental>home health>other professional>non-durable med>durable med)

Government Provided Insurance in US

Introduction to the Health Care Systems in US

• Medicare: >65 years, some disabled, with end-stage renal disease
• Medicaid: low-income, disabled
• Veterans
• Government employees
• Native Americans

Health Resources Services Administration in US

Introduction to the Health Care Systems in US

• Grant-supported federally qualified health centers (i.e. community health centers, migrant health centers, healthcare for homeless programs, public housing primary care programs)
• Federally qualified health center look-alikes
• Outpatient health programs/tribal organizations

Publicly Funded Health Care in US

Introduction to the Health Care Systems in US

• Medicare, Medicaid, and CHIP=1/3 of total health care expenditure
• Rest used for Dept of Defense, Dept of Veterans' Affairs, non-commercial medical research, Workers' Compensation programs, State-only general assistance programs, public medical facilities, maternal and child heatlh services, school, Indian health, substance abuse and vocational rehabilitation services

Affordable Care Act Coverage Provisions for 2014 in US

Introduction to the Health Care Systems in US

• Medicaid to all w income <138% of Federal poverty level
• Enrollment in CHIP to increase
• Private health insurance expenditure growth, out-of-pocket spending to decrease
• 92.7% population with health insurance by 2019

Objectives:

Introduction to the Health Care Systems in US

• Describe organization of US health care system
• Reflect on how US spends its health care dollars
• Identify sources of funds spent on health care in US

Nation's Health Dollar in US

Introduction to the Health Care Systems in US

• Health Insurance 71% - private health insurance>Medicare>Medicaid federal>Medicaid state and local>VA, DOD, and CHIP 
• Out of pocket 12% 
• Third-party payers and programs 7%
• Investment 6%
• Government public health activities 3%

Medical Humanities

Introduction to the Medical Humanities

Reasoning for Medical Humanities

Introduction to the Medical Humanities

Abraham Flexner argued for humanistic education and aquisition of humanistic skills to

• Provide insight into suffering
• Emphasize perspective and individuality of each patient
• Offer historical perspective of medicine 
• Develop and nurture skills of observation, analysis, empathy, and self-reflection
• Understand how bioscience and medicine take place within cultural and social contexts
• Follow a logical narrative thread, justify a decision, interpret data, seek evidence, and draw analogies
• Recognize meaning in seemingly random events, tolerate ambiguity, adopt others' perspectives, frame events within social and historical perspectives, reconcile competing values

 Reasons for this field:

• Medicine and humanities have always been interwoven
• Great literature written by and about physicians
• Medical practice always operated with guidance of ethics, law, and religion
• Work and science of healing has been a focus of philosophers and historians
• Care of sick and dying has incited physicians over the ages to ponder meaning of life
• Doctors grow to realize that their knowledge of body and disease needs to be foritifed by another kind of knowledge-of values, of nuances, of individuals

Visual Thinking Strategies

Introduction to the Medical Humanities

Developed by cognitive psychologist Abigail House and art educator Philip Yenawine

• What's going on in this picture?
• What do you see that makes you say that?
• What else can you find?

Students increased amout on time looking at art/patient images, number of words to descibe, number of observations made, increased tolerance for ambiguity

Objectives:

Introduction to the Medical Humanities

• Discuss importance of medical humanities in medical education and practice of medicine
• Present existing evidence for use of humanities in medical education
• Present representative pieces within realm of medical humanities
• Review integration of humanities within MD/MPH curriculum

Sir William Osler

Introduction to Interviewing

Best known for his publications on traditional bedside manner

Medical Interviews

Introduction to Interviewing

• Personal and intimate
• Confidential
• Help to establish physician-patient relationship
• Help solve problems: not just fact-finding
• Integrate patient-centered with past practice of doctor-centered interviewing

Doctor-Centered Interviewing and Its Negatives

Introduction to Interviewing

• The interviewer is in charge of interaction to learn about symptoms, and other information to help make diagnosis
• Personal concerns are not a priority
• Effect of illness on patient is not given high value

 Negatives:

• Incomplete history
• Physicians interrupt patients during chief complaint in 70% of office visits
• Interruptions occur after average of 18 seconds
• Less than 10% of problems ultimately found to be psychosocial are found

Patient-centered Interviewing

Introduction to Interviewing

• Relationship-centered approach that encourages patients to talk about what is most important to them
• Symptoms and personal concerns are expressed
• Patients allowed to lead with concerns and fears, desire for information, clarification of issues, effects on family/job/finances

Positives of Integration of Patient and Doctor-centered Interviewing

Introduction to Interviewing

• Improved patient satisfaction
• Improved compliance
• Patient knowledge and recall are improved
• Decrease in malpractice claims
• Improved health outcomes
• Use of open-ended questions allows patient to clarify feelings, involves patient in problem-solving process, and allows for shared-decision making

Attentive Listening

Introduction to Interviewing

• Demonstrates interest and concern in non-verbal way
• Encourages patient to open up
• Utilize eye contact, gestures, expressions
• Avoid distractions
• Reflect, facilitate, clarify, direct, summarize, and always end interview with "is there anything we have not covered that you would like to talk about?"

Steps of an Interview

Introduction to Interviewing

Step 1 

• Welcome patient
• Identify patient by name
• Introduce yourself and identify your role
• Ensure privacy
• Remove barriers to communication
• Ensure comfort and put patient at ease

Step 2

• Chief complaint and other concerns
• Discuss time available
• Indicate your own needs
• Identify all issues patient wishes to discuss
• Summarize

Step 3

• Opening the HPI
• Ask open-ended question
• Use attentive listening
• Observe data from non-verbal cues, physical characteristics

Objectives:

Introduction to Interviewing

• Identify attributes of effective medical data gathering, including accuracy, thoroughness, relevance, and efficiency
• Describe patient-centered interviewing and its contribution to medical interview
• Define following specific data-gathering communication skills and describe their use (attentive listening, open-ended and close-ended questions, reflection, facilitation, clarification and direction, checking and summarization)

Stress

Medical Student Wellness

• Stress is a condition experienced when a person perceives that demands exceed the personal and social resources the individual is able to mobilize
• Reaction to events, environmental or internal, that challenge or exceed our adaptive resources
• Not all stress is bad
• Physical, psychological, social, financial, academic, clinical training
• Stages of stress: 1. symptoms (psychological, physical), 2. persistent symptoms (behavior), 3. burnout

Burnout

Medical Student Wellness

• State of mental and physical exhaustion caused by excessive and prolonged stress
• Chronic sadress or depression
• Chronic anxiety, irritability, and anger
• Chronic fatigue and headaches
• Chronic stomach and bowel problems
• Powerlessness, hopelessness, trapped, desire to escpae, detachment, isolation, cynicism, loss of ideals, blunted emotions, apathy
• Affects at least 50% of medical students

Sleep Deprivation

Medical Student Wellness

• Avg student sleep requirement 8 +/- 1 hr
• Sleep debt is cumulative and does not go away
• Symptoms include daytime drowsiness, fatigue, poor concentration and memory, irritability and moodiness, impaired performance, increased accidents
• Cognitive effects include impairment of complex, high-ordered tasks

Acute Stress Management

Medical Student Wellness

• Stress-relief activities, sleep and proper diet
• Changing negative, catastrophic thinking
• Imagery before event takes place
• Get support

Objectives:

Medical Student Wellness

• How to recognize signs of stress
• Identify methods to reduce stress and improve wellness
• Discuss how lack of personal wellness can be a hindrance to the doctor-patient relationship

Chronic Disease

The Many Facets of Chronic Illness

• Duration of illness > 1 yr
• Can be controlled but often not treated
• i.e. heart disease, stroke, cancer, chronic respiratory disease, diabetes
• Leading cause of mortality in world and leading cause of death and disability in US

Chronic Disease Epidemiology

The Many Facets of Chronic Illness

• An invisible epidemic that hinders economic development [80% chronic disease deaths in low-mid income countries]
• 1 of 2 adults in US had at least one chronic illness
• Percentage of adults with multiple chronic illnesses increases with age and poverty level

Common Chronic Diseases in US

The Many Facets of Chronic Illness

Children

• Allergies
• Asthma
• Learning disabilities
• ADHD

Adults

• HT
• Arthritis
• Heart disease
• Diabetes

[Heart disease> cancer> lower respiratory disease> stroke> accidents> alzheimer's> diabetes> influenza and pneumonia> nephrosis> suicide

Arthritis is leading disability in US]

Chronic Respiratory Diseases

The Many Facets of Chronic Illness

• Emphysema
• Chronic obstructive pulmonary disease (caused by smoking)
• Asthma

Mental Illness as Chronic Disease

The Many Facets of Chronic Illness

• 50% with mental illness have >1 disorders
• Alcoholism and substance abuse are chronic illnesses

WHO Chronic Disease Risk Factors

The Many Facets of Chronic Illness

• Alcohol
• High bp
• High cholesterol
• Low fruit and vegetable consumption
• Overweight and obese
• Physical inactivity
• Tobacco use
• Diabetes
• Oral health
• Visual impairment

Impact of Chronic Disease

The Many Facets of Chronic Illness

• Activity limitations
• Psychological
• Interpersonal 
• Professional
• Economic

Barriers to Optimal Chronic Illness Care

The Many Facets of Chronic Illness

• Lack of access to care (lack of insurance, no sick leave benefits, no transportation, inadequate scheduling)
• System-centered care (patients have to navigate increasingly complex health care systems)
• Doctor-centered care (physician availability, competence, inadequate opportunities for patients to learn self-management skills)
• Insufficient health literacy (may effect medication use, informed consent, insurance, navigation)
• Inadequate cultural competency
• Fragmentation of care (inadequate coordination and communication between practitioners, EMR not used

Optimize Prevention of Complications

The Many Facets of Chronic Illness

Individual level: primacy of patient welfare

• advocacy, competence, communication, patient perspective, patient-centered, health literacy, cultural competence, systems-based, collaboration

Societal level: social justice

• advocacy, development of patient-centered, involvement in collaborative efforts, community outreach, public policy, research

Palliative Care vs. Hospice

The Many Facets of Chronic Illness

 Palliative Care

• Symptom management 
• Focus on quality of life 
• Multidisciplinary care
• Relieves suffering as opposed to focus on cure
• Provides relief from pain and other symptoms
• Affirms life and regards dying as normal
• Intends neither to hasten or postpone death
• Integrates psychological and spiritual care
• Offers support system to help patients live actively
• Offers support for family
• Uses team approach to address all needs
• May begin at time of diagnosis

Hospice

• Symptom management
• Focuses on quality of life
• Multidisciplinary care
• Prognosis of 6 months or less
• Focuses on comfort care and agressive measures stopped

Objectives:

The Many Facets of Chronic Illness

• Review prevalence of chronic illness in US
• Name some of the most common chronic diseases in children and adults in US
• Discuss potential impact of chronic illness on someone's life
• Describe some of the potential systems barriers to achieving high quality of care for all patients with chronic illnesses
• Develop a working definition of palliative care

7 Descriptors of a Symptom during HPI

Patient-centered and Doctor-centered Interviewing

• Location and radiation
• Quality
• Severity
• Chronology and timing
• Setting
• Aggravating and alleviating factors
• Associated symptoms

Past Medical History

Patient-centered and Doctor-centered Interviewing

• Childhood illnesses
• Adult illnesses
• Previous hospitalizations
• Operations
• Accidents/injuries
• Obstetric history
• Transfusions

Social History

Patient-centered and Doctor-centered Interviewing

• Marital status
• Living conditions
• Empoyment
• Sexual history
• Diet/exercise
• Habits (substance use)
• Significant life events

Family History

Patient-centered and Doctor-centered Interviewing

• Relatives: age, health, cause of death, age at death
• Significant illnesses in the family

Medications and Allergies

Patient-centered and Doctor-centered Interviewing

• Current medications: name, dose, reason, adverse effects
• Allergies; sensitivities; drug reactions

Review of Systems

Patient-centered and Doctor-centered Interviewing

• Review systems
• Ask about other symptoms
• General or constitutional symptoms
• Emotional symptoms

Patient-Centered Communication and Cultural Issues

Patient-centered and Doctor-centered Interviewing

Objectives:

Patient-centered and Doctor-centered Interviewing

• Describe an effective process of opening an interview, including steps involved in setting stage
• Define chief complaint as primary reason for seeking care and set agenda for interview
• Describe steps involved in opening HPI
• Describe patient-centered HPI
• Define steps used to transition during interview
• Describe components of comprehensive medical history

Ways to Measure Healthy Lives

Challenges in Health Care and Quality Management

• Mortality amenable to health care
• Infant mortality rate
• Healthy life expectancy at age 60
• Adults under 65 limited in any activities because of health problems
• Children who missed 11 or more days of school due to illness or injury

Quality of Health Care

Challenges in Health Care and Quality Management

• Effective care (adults received recommended screening and preventive care, children received immunization and preventive care, needed mental health care and received treatment, chronic disease under control, hospitalized patients receive recommended care for heart attack, pneumonia)
• Coordinated care (Adults under 65 with accessible primary care, children with medical home, hospital discharge coordination, nursing home, home health)
• Safe care (lab test error, unsafe drug use, nursing home residents with pressure sores, hospital-standardized mortality ratios, surgical infection prevention, complications of care in hospitals)
• Patient-centered, timely care (see doctor when sick, care after hours without ER, physician attentiveness, self-management plan, patient-centered hospital care, physical restraints in nursing home)

Access

Challenges in Health Care and Quality Management

Participation

• Adults under 65 insured all year, no access problem due to costs

Affordability

• If low-income not spending much out-of-pocket, employed have less than 15% premium, under 65 no medical bill problems,

Efficiency

Challenges in Health Care and Quality Management

• Potential waste
• ER for condition that could have been treated otherwise
• Medicare hospital 30-day readmission rates
• Medicare costs of care and mortality for heart attacks, hip fractures, or colon cancer
• Medicare costs for chronic diseases
• Health insurance administration as % total national health expenditures
• EMR

Equity

Challenges in Health Care and Quality Management

• Risk rations by insurance, income, and race

Challenges in US Health Care 

Challenges in Health Care and Quality Management

• Access to care
• Care for uninsured
• Caring for elderly
• Medical liability
• Paying for medications
• Adaptation of new technology and treatments
• Health care quality
• Health care expenditures and sustainability

Strategies to Better US Health Care

Challenges in Health Care and Quality Management

• Health care reform (emphasis on prevention, health info technology, better management of chronic diseases, pay based on outcomes, preferred treatment)
• Medical home
• Incentives for high quality care (public reporting on performance)
• Physician and hospital report cards (board certification status, health plan employer data and information set -> disincentive to provide care for high risk patients)

Objectives:

Challenges in Health Care and Quality Management

• Enumerate major challenges in health care including access to care, care for uninsured, care for elderly, medical liability, paying for medications, adaptation of new technology and treatments, health care quality
• List major strategies currently being pursued to address problems in US
• Describe importance of quality in health care and major areas of care where quality may be lacking
• Discuss accreditation process for insurance companies, hospitals, and clinics in US

Blood Pressure

Vital Signs

Equipment

• Stethoscope
• BP cuff - if size too small->BP read higher and if too big->BP read lower; inflatable bladder length should be 80% and width should be 40% circumference of upper arm; mark placed above brachial artery
• Sphygmomanometer - anaeroid or mercury

Procedure for taking BP

• Patient avoid caffeine and smoking -30 min
• Should sit on chair with feet on floor
• Remove clothing from area
• History of HT, slow or rapid pulse, current medications info obtained
• Lower border of cuff placed 2.5 cm above antecubital crease (4th rib interspace) and secured with patient's arm slightly flexed at heart level
• Palpate bracial artery to confirm pulse viable and place steth over brachial artery
• Inflate cuff to 30 mmHg above estimated systolic ~ 180 mmHg and release at 2-3 mmHg/sec
• Record systolic and diastolic to nearest 2 mmHg

Systolic and Diastolic Pressure

 Vital Signs

Systolic

• Level at which hear sounds of two consecutive beats (Korotkoff sounds)
• At rest, blood flow laminar and silent 
• As cuff deflated, SBP exceeds cuff pressure
• As blood begins to spurt through compressed artery, turbulent flow is audible and vibrations in artery walls are called Korotkoff sounds
• Sounds divided into 5 phases: sharp thid, blowing/swishing, softer thud, softer blowing, silence

Diastolic

• Pressure at which sounds muffle and disappear and confirm pressure falling for 10-20 mmHg 
• Auscultatory gap is region between SBP and DSP for 10 mmHg

Special situations

• Orthostatic BP - measure BP and heart rate in 2 positions as supine and standing up; normal = systolic < or same and diastolic >; orthostatic HT = systolic drop > 20 or diastolic of 10 mmHg
• Weak Korotkoff - incorrect steth placement, venous engorgement of arm from repeated readings
• Arrhythmias - determine avg atrial fibrillation
• Obese - wide cuff
• HT unequal BP in arms/legs - coarctation of aorta due to narrowing of thoracic aorta with higher BP in upper extremities

 Normal BP 120/80, HT1 140-159/90-99, HT2 160/100

Heart Rate and Rhythm

Vital Signs

• Radial pulse for heart rate using index and mid fingers for 15 sec unless irreg
• Regularity of pulse (reg irreg or irreg irreg or reg)

Normal adult HR 60-100, tachy>100, brady<60

Respiratory Rate

Vital Signs

• Visual inspection or steth to trachea

Normal adult RR 10-20, tachy>20 (rapid and shallow), hyperventilation (rapid and deep), brady<10 (slow), apnea (pauses greater than 20 sec)

Temperature

Vital Signs

• Oral temp 96.4F am to 99.1F pm
• Rectal temp higher by .9F
• Axillary temp lower by 1F
• Tympanic membrane higher by 1.4F

Objectives:

Vital Signs

• Describe significance of vital signs, invluding BP, heart rate, respirations
• Describe and demonstrate acceptable techninques for measurement of BP, heart rate, respirations, temp
• Describe potential confounders of accurate BP measurement and possible remedies
• Define HT in adults

Objectives:

Effective Communication with Patients

• Describe key components on effective communication
• Reflect on impact of effective communication on patient-physician relationship
• Discuss potential barriers to developing an ideal patient-doctor relationship
• Identify strategies that could be applied by physicians to help ovecome some of the potential barriers to an ideal relationship

Key Components of Effective Communication

Effective Communication with Patients

• Being human
• Establishing trust
• Exhibiting empathy, compassion
• Being attentive; actively listening
• Allocating sufficient time
• Conveying understanding
• Awareness of feelings
• Respecting patient's dignity, privacy, and confidentiality
• Exhibiting honesty and trustworthiness
• Remembering that you are being evaluated by patient

Enhancing Doctor-Patient Relationship

Effective Communication with Patients

• Genuine care and compassion
• Acquire skills to bond quickly
• Give patient full attention
• Apologize if late or distracted
• Avoid acting arrogant
• Be respectful
• Be prepared to react and respond
• Set aside time to review, return phone calls, and document conversations
• Avoid criticizing colleage
• Demonstrate humor 
• Never be reluctant to say I don't know
• Shared-decision making
• Never assume

Objectives:

Mindful and Reflective Practice

• Define goals of mindful and reflective practice
• Discuss how Kolb's experiential learning model may be applied to reflective practice
• Explain how mindful and reflective practice promote intra- and interpersonal awareness and growth
• Describe mindful and reflective practice as strategies to learn from experiences and to reduce the occurrence of unintended outcomes

Mindfulness

Mindful and Reflective Practice

• Being cognizant of one's own thoughts, feelings, and actions at all times and aware of the moment as opposed to being distracted by past or future events
• Attentive observation, critical curiosity, an open mind, presence
• Mindful physician also aware of own wellness and allow for necessary interventions since that effects outcomes and patient care
• Goal: recognize how our decision-making is affected by stereotypes, biases, and heuristics, increase awareness, personal and progessional growth, build empathetic relationships, recognize errors, relieve suffering

Explicit vs. Tacit Knowledge

Mindful and Reflective Practice

Reflective Practice

Mindful and Reflective Practice

• Opportunity to learn from experiences through critical reflection
• Critical reflection is crucial for learning from unintended outcomes
• Perspective taking
• Unstructured vs. systematic manner

Cognitive Medical Errors

Mindful and Reflective Practice

Kolb's Experiential Learning Cycle

Mindful and Reflective Practice

• To lend structure to reflective practice; applied to enhance learning, teaching, and critical thinking
• Concrete experience (identification of a problem, dilemma, conflict, LI)->
• Reflective obsrvation (looking at all aspects of problem i.e. assumptions/biases present, other's perspective, evoked emotions)->
• Abstract conceptualization (learned what from the event and how to improve approach to similar situations in future)->
• Active experimentation (apply what has been learned)->back agian

Objectives:

Eliciting Feedback and Taking Charge of your Education

• Review definition of practice-based learning and improvement competency
• Reflect on importance of dedication to life-long learning and commitment to excellence to provide optimal patient care
• Describe basic strategies for effective feedback
• Effectively elicit feedback from faculty and peers as a strategy to optimize learning
• Discuss keeping a journal and learning portfolio as a strategy to optimize personal and professional growth, including learning from feedback

PBL and Improvement

Eliciting Feedback and Taking Charge of your Education

• Medical students: initiative at improving own learning, facilitate learning of others
• Residents: analyze practice experience, locate/appraise/assimilate evidence from scientific studies related to patients' health problems, apply knowledge of study designes and statistical methods to appraisal of clinical studies and other info on diagnostic and therapeutic effectiveness, obtain info about their own pop of patients and larger pop, use IT to manage info, facilitate learning
• Physicians: optimize practice and patient care through EBM, quality improvement, individual improvement

Importance of Feedback

Eliciting Feedback and Taking Charge of your Education

• Key step to acquisition of clinical skills
• Highlights differences between intended result and actual results
• Presents info unlike an evaluation
• If not given, mistakes go uncorrected and good performance not reinforced

Reasons Feedback Avoided

Eliciting Feedback and Taking Charge of your Education

• Lack of observation/commitment
• Time
• Fear of hurting someone's feelings
• Perception that student may only want feeding
• Fear of eliciting defensiveness and other negative responses

Elements of Feedback

Eliciting Feedback and Taking Charge of your Education

• Should be undertaken with both parties working as allies with common goals
• Should be well timed and expected
• Should be based on first-hand data
• Should be regulated in quantity and limited to behaviors that are remediable
• Should deal with specific performance, not generalizations
• Should offer subjective data
• Should deal with decision and actions, rather than assumed intentions or interpretations

Feedback Steps

Eliciting Feedback and Taking Charge of your Education

Objectives:

Practice Environment: Communication with Colleagues

• Appreciate importance of multi-disciplinary collaboration on patient care
• Discuss communicating with consultants
• Discuss communicating with other colleagues in health care setting
• Develop a method for setting expectations with your preceptors
• Reflect on introductions in clinic setting

ACGME: Core Competencies

Practice Environment: Communication with Colleagues

• Patient care
• Medical knowledge
• Professionalism
• Systems-based practice (awareness of and responsiveness to larger context and health care system, call effectively on other resources
• Practice-based learning and improvement
• Interpersonal and communication skills (effective exchange of info and teaming with patients, their families and health professionals across socioeconomic and cultural backgrounds, act as consult to other physicians, maintain comprehensive, timely, and legible medical records

Communication is Key

Practice Environment: Communication with Colleagues

Relationship between teamwork and improved clinical processes and patient outcomes

• Reduced medical errors
• Improved surgical team performance
• Better provider adherence to clinical to clinical guidelines
• Lower hospital lengths of stay
• Greater gains in patient functional
• Status
• Reduced patient mortality

Coordination + Integration = health care communication

Institute of Medicine

Practice Environment: Communication with Colleagues

• Established in 1970 by National Academy of Sciences
• IOM as an adviser to federal government on medical care issues
• IOM provides independent, objective, evidence-based adviced on how to improve health, "crossing quality chasm"
• Provides strategic direction for redesigning health care delivery system
• Goals: safe, effective, timely, equitable, patient-centered

Patient-Centered Care: Coordination + Integration

Practice Environment: Communication with Colleagues

Consultants

• Answer specific question regarding patient
• Provide basic and essential patient info that consultant needs to answer question
• Not involved with overall care of patient

Patient-Centered Care: Info, Education, and Comm

Practice Environment: Communication with Colleagues

• Info that patient wants and education that patient needs

Preceptor-Student Relationship

Practice Environment: Communication with Colleagues

• Resource for students
• Establish how to introduce selt and set expectations
• Learning contract=setting expectations together specific to integrated patient care course, 5 professional goals, 2 personal goals
• Informally after each session praise, constructie criticism on history taking, questions from patient interaction, agenda for next patient encounter or preceptor visit

Objectives:

Cultural Competency

• Define race, ethnicity, culture, and cultural competence
• Reflect on the need for a cultural competency curriculum in medical training
• Discuss potential effects of cultural background, bias, and stereotyping on the medical interview and health care outcomes
• Apply curiosity, empathy, and respect to enhance the medical interview
• Identify clinical tools to assist in obtaining a cultural and social history in the future

Race

 Cultural Competency

• A socially defined population that is derived from distinguishable physical characteristics that are genetically transmitted
• More of a social construct than biological

Ethnicity

Cultural Competency

• Groups that share ancestry, nationality, religion, or language

Culture

Cultural Competency

• Shared system of values, beliefs, and learned patter of behaviors within any group
• Race, ethnicity, age, socioeconomic status, religion, gender, sexual orientation, occupation, disability, geographic origin, educational level
• Since no 2 people share the exact same set of values, beliefs, and behaviors, every encounter can be thought of as a cross-cultural experience

Cultural Competency

Cultural Competency

• Competence: capacity to function effectively
• Cultural competency: a set of skills that allows for increased understanding and appreciation of cultural differences between groups, enables professionals to work effectively in cross-cultural situations, never ending developmental process
• Utlimate goal: health care system that can deliver highest quality of care to ever patient, regardless of race, ethnicity, cultural background, or English proficiency

Diversity and Disparities in Health Care

Cultural Competency

• Physician population not keeping pace with diverse patient population, creating possibility of racial and ethnic discordance between physicians and patients in most regions of the country
• 1999 Congress requested IOM access care across racial and ethnic varieties and found unequal treatment
• Disparities exist primarily in infant mortality, heart disease, AIDS, diabetes, mental illness, cancer, immunization and African, Hispanic, Asian aknowledge this disparity
• African Americans die of coronary heart disease higher than white patients; minority amputated more than white for diabetes
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How to Increase Cultural Competence

Cultural Competency