Structured Group Reflection and Improvisation: Developing skills for the medical home in a variety of cultural settings Daisuke Yamashita MD1, Kenichi Yokobayashi MD2, Morito Kise MD 3, Yasuki Fujinuma, MD2, Randall Longenecker, MD4 1. OHSU Family

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Structured Group Reflection and Improvisation
Developing skills for the medical home in a
variety of cultural settingsDaisuke Yamashita
MD1, Kenichi Yokobayashi MD2, Morito Kise MD 3,
Yasuki Fujinuma, MD2, Randall Longenecker, MD41.
OHSU Family Medicine 2. HCA-JCCU Family Medicine
Residency Program Tokyo 3. Kawasaki Municipal
Tama Hospital Family Medicine Residency 4. The
Ohio State University Rural Program
HCA-JCCU Family Medicine Residency Program Tokyo
The Ohio State University Rural Program
Diffusion of an innovation 1998 Shaughnessy AF,
Slawson DC, Becker L. Clinical jazz Harmonizing
clinical experience and evidence-based medicine.
J Fam Pract 199847425-8. 1999 Birth of
Clinical Jazz as introduced by Dr. Longenecker
at Mad River Family Practice in Ohio. 2005 April
Dr. Fujinuma found Dr. Longeneckers presentation
on internet. 2005 May Dr. Yamashita met Dr.
Longenecker at an STFM conference in San
Francisco 2006 April Clinical
Jazz was adapted to the residency in Tokyo (Dr.
Fujinuma and Dr. Yokobayashi) 2006 April
Clinical Jazz was adapted to the residency in
Kawasaki (Dr. Kise) 2006 July Dr. Yamashita
moved to OHSU, Portland Oregon for
residency. 2007 March Dr. Fujinuma and Dr.
Yokobayashi received Best Teaching Pearl Award
at 15th Japan Society of General Medicine annual
conference. 2008 July Clinical Jazz was
adapted to OHSU Family Medicine South Waterfront
clinic (Dr. Yamashita)
Background-Patient-Centered Medical home (PCMH)
is becoming center piece of future
practice -In PCMH we will expect to see
followings. 1. Surprising problem but not
limited to medical condition 2. Complex,
with multiple layers of socio-
psychological meaning and involving multiple
relationships. -Training in uncertainty and
complex bio-socio- psychological is essential
in the residency training to implement PCMH.
Challenges 1. Requires experienced facilitator
to lead discussion. -Discussion may become
scattered and unfocused. -A facilitator can avoid
this by keeping the group focused on the
original question. 2. Difficulty formulating
clinical pearls, i.e. taking the action
turn -Requires everyones participation to come
up with pearls forces improvisation -Improves
over time as group becomes used to this
process. 3. Difficulty finding evidence in
literature.
Dr. Yasuki Fujinuma, Dr. Kenichi
Yokobayashi Setting Based in Tokyo, Japan. Total
of 11 residents with 10 faculties. Network of 6
urban clinics. Emphasis on home care and
geriatric care. Name "Clinical Jazz" When
Once a month at the residency conference. Time
30 minutes x 2 cases Who Residents and Faculty
Dr. Randall Longenecker Setting Mad River Family
Practice, West Liberty, Ohio. A 2-2-2
integrated rural training track residency Name
Clinical Jazz and Faculty Jam When Weekly,
on Thursdays Time 75 minutes, single case Who
Residents, Faculty (including residency
coordinator and clinical psycologist), and
visiting students or other guests (Faculty Jam
is for faculty only)
Discussion Clinical Jazz was successfully
implemented among four different residencies in
different clinical and cultural settings.
"Clinical Jazz" promotes relationship centered
medicine, reflective practice and balancing
evidence and experience in different cultural
contexts and provides a safe educational home
for difficult cases This suggests that "Clinical
Jazz may be useful in a patient centered medical
home, dealing with cases of great complexity and
uncertainty.
Next steps -Share "Clinical Pearls" among
residencies. -Develop evaluation tools to measure
effectiveness of the "Clinical Jazz" on
promoting reflective practice. -Evaluate the
impact upon patient care -Incorporate other
clinical staff in the setting of a patient
centered medical home, further promoting
team-based care.
Dr. Daisuke Yamashita OHSU Family Medicine South
Waterfront Clinic Based in Portland Oregon. In
large academic medical center. Part of OHSU FM
residency. Total of 12 residents in this clinic.
Urban setting and patients with diverse ethic
background. Name Difficult Case Conference
When Once a month at the clinic Time 30
minutes x 2 cases Who Residents, faculties and
a clinical psychologist
Dr. Kise Morito Based in Kawasaki, Japan. City
next to Tokyo. The clinic is part of 300-bed
community hospital. Total of 7 residents.
Emphasis on inpatient, pediatrics and emergency
care. Title Clinical Jazz When twice a
month Time 60 min x1 case Who Residents and
Faculties.

• Clinical Jazz
• A semi structured small group process designed to
  promote reflection and develop skills working in
  a complex, relationship-rich environment.
• 1. Pick an emotionally moving case, prompting
• surprise, sadness or confusion. (self
  reflection)
• 2. Draw a Genogram (relationship centered)
• 3. Open discussion with group. Everybody
  participate!
• EBM and experiences are woven in the
  discussion.
• 4. Conclude with a clinical pearl
• 5. Reflect on the case and proceed to practice

Contacts Daisuke Yamashita M.D. yamashid_at_ohsu.edu
Kenichi Yokobayashi M.D. yokobayashi_at_hotmail.co.
jp
OHSU Family Medicine
Kawasaki Municipal Tama Hospital Family
Medicine Residency