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Orientation to the Family Medicine Clerkship

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In 1987 the National Medical Expenditure Survey reported that 82% of Americans ... 1 is hospitalized in an academic medical center. Orientation to TOPICS Curriculum ... – PowerPoint PPT presentation

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Title: Orientation to the Family Medicine Clerkship


1
Orientation to the Family Medicine Clerkship
  • Darwin Deen, MD, MS
  • 2004-2005

2
IOM Definition of Primary Care
  • Generalist health care is continuous,
    comprehensive, and coordinated medical care
    provided to a population undifferentiated by age,
    gender, or organ system.

3
Primary care is not a discipline or specialty but
a function that is essential as the foundation of
a successful, sustainable health care system.
Institute of Medicine
4
Characteristics of Primary Care
  • First Contact- undifferentiated by illness,
    triage function, case manager (coordinates the
    patients care regardless of where provided or by
    whom)
  • Continuous- over time (longitudinal), not limited
    by age group
  • Comprehensive- preventive, diagnostic and
    curative/therapeutic

5
Patients and their Doctors
  • In 1987 the National Medical Expenditure Survey
    reported that 82 of Americans has a usual
    source of care.
  • In 1994 80 of adults completing the General
    Social Survey reported a regular personal
    doctor.
  • In 1996 the Medical Expenditure Panel Survey
    found that 77 of households had a usual primary
    care provider

6
Primary Care Competencies (USDHHS)
  • Health promotion and disease prevention
  • Assessment and diagnosis of common symptoms and
    signs
  • Management of common acute and chronic medical
    conditions
  • Identification of and appropriate referral for
    other health services

7
Crossing the Quality Chasm
  • Characteristics of high-quality healthcare
  • safe
  • timely
  • effective
  • efficient
  • patient-centered
  • equitable

Institute of Medicine 2002
8
Future of Family Medicine
  • The attributes of Family Medicine are
  • continuity,
  • comprehensiveness,
  • first contact,
  • community, and
  • family.

http//www.annfammed.org/cgi/content/full/2/suppl_
1/s3
9
Fundamental Principles of Family Medicine
  • Access to Care
  • Continuity of Care
  • Comprehensive Care
  • Coordination of Care
  • Contextual Care

10
Access to Care
  • Access issues deal with how patients use the
    health care system
  • (including who, when why)

11
Continuity of Care
  • Continuity deals with how doctor-patient
    relationships develop, change, and end
  • Dimensions include chronologic and geographic
    continuity, and continuity of generalism and for
    families

12
Comprehensive Care
  • Deals with the scope of practice and extent of
    services delivered

13
Coordination of Care
  • How physicians organize and manage the care they
    deliver.
  • Health promotion and preventive services
    including screening and immunizations.
  • The specialty referral process care for
    special populations.

14
Contextual Care
  • How the health care problems of the individual
    patients are placed in a context (biomedical,
    psychological, individual, family, community, and
    social). What the illness means to the patients
    life.

15
Who is in Control of the Environment surrounding
a locus of care?
Environmental Aspect Hospital Office
16
DFSM Clerkship
  • Three Components
  • Clinical Experience
  • Community Experience
  • Case-based discussions and Didactics

17
The Ecology of Medical Care
1,000 People In Community
750 Will Report an Illness/Injury
250 Will Seek Care
9 Admitted
3 Referred
1 University Admission
White KL, et al, N. Engl J Med, 1961 265885-92
18
1,000 Persons
800 Report Symptoms
327 Consider Seeking Medical Care
217 Visit physicians office (113 primary care
physician)
65 Visit complimentary or alternative medical
provider
21 Visit a hospital outpatient clinic
14 Receive home health care
13 visit emergency dept.
lt1 is hospitalized in an academic medical center
19
Orientation to TOPICS Curriculum
20
Future of Family Medicine
  • The core attributes of family medicine are
    organized into 4 discrete domains
  • 1) the management of knowledge and information,
  • 2) the management of relationships,
  • 3) the management of processes, and
  • 4) cultural proficiency.

http//www.annfammed.org/cgi/content/full/2/suppl_
1/s3
21
5 Types of Visits
  • New Problem (Acute Care)
  • Checkup (Health Maintenance)
  • Chronic Illness (Routine Follow-up)
  • Psychosocial
  • Behavior Change

22
Major Tasks
  • Physician Information Processing
  • Data acquisition and synthesis
  • Patient-physician relationship development
  • Integration of information and relationship
  • Lifelong learning

23
Major Tasks
  • Physician Information Processing
  • How does the history-taking or other data
    gathering differ for each different type of
    visit?
  • Patient-physician relationship development
  • How do different types of visits promote
    relationship development?
  • Integration of information and relationship
  • Lifelong learning
  • How are your learning needs different for each
    type of visit?

24
What are the tasks that need to be accomplished
in the primary care ambulatory setting?
  • Making a new diagnosis
  • Patient presents with an undiagnosed complaint or
    set of symptoms.
  • How do we evaluate a symptom?
  • How do we decide who needs further evaluation
    (tests) or referral?

25
What are the tasks that need to be accomplished
in the primary care ambulatory setting?
  • 2. Health Maintenance visits
  • These visits should be seen as an opportunity to
    accomplish primary prevention.
  • What interventions are indicated for patients in
    each age/sex group?
  • What interventions are evidence-based? How do we
    know?
  • What interventions are cost-effective? (e.g.
    breast self-exam)
  • How do we prioritize? (e.g. dietary counseling in
    unselected patients)
  • This examines how we know what to do and what
    resources are available to help us.

26
What are the tasks that need to be accomplished
in the primary care ambulatory setting?
  • 3. Follow-up visit for ongoing treatment of a
    known medical problem.
  • e.g. follow-up of a previously diagnosed acute
    problem or for chronic disease management
  • What is important in the management of this/these
    chronic disease/s?

27
What are the tasks that need to be accomplished
in the primary care ambulatory setting?
  • 4. Emotional support how do we help patients in
    need of acute or ongoing psychological treatment?
  • BATHE technique
  • SPEAK treatment model
  • When how to refer

28
What are the tasks that need to be accomplished
in the primary care ambulatory setting?
  • 5. Behavior Change visit
  • For primary or secondary prevention and/or
    patient education
  • Self-care
  • Chronic disease management

29
For each of the visit types, what information do
you need to successfully handle this visit?
  • Information from the patient in the form of
  • history
  • physical examination findings
  • medical record
  • laboratory tests
  • imaging studies
  • provocative tests (stress tests, PFTs)
  • or invasive testing (cardiac cath, biopsy, etc)
  • Information from the medical literature
  • Information from consultants
  • Patient education material

30
New problem
  • Assess presenting complaint
  • History and physical exam
  • Construct a differential diagnosis
  • Assess patients expectations and concerns
  • Build rapport and develop the relationship
  • Communicate diagnosis
  • Negotiate management plan
  • Support patient self-care
  • Learn from the encounter by reviewing applicable
    diagnostic or therapeutic protocols.

31
Health Maintenance Check-up
  • Assess risk based on Family Hx, risk factors and
    prior preventive services for CA, CHD, ID,
    injury, metabolic and emotional health.
  • Recommend/perform preventive services
  • Assess patients expectations and concerns. Build
    rapport and develop the relationship
  • Negotiate prevention plan and support self care.
  • Learn by reviewing US Preventive Services Task
    Force Recommendations.

32
Chronic Disease Follow-up
  • Assess severity and control of condition
  • Evaluate adherence and side effects of treatment
  • Scan for target organ damage
  • Review status of co-morbid conditions
  • Assess patients expectations and concerns. Build
    rapport and develop the relationship.
  • Assess patients learning needs.
  • Renegotiate management plan support self-care.
  • Learn from the encounter by reviewing relevant
    clinical guidelines.

33
Psychosocial
  • Assess emotional needs of patient or family
  • Background
  • Affect
  • Trouble
  • Handling
  • Empathy
  • Evaluate for diagnosable mental illness
  • If depressed, evaluate suicide risk
  • Assess patients expectations and concerns. Build
    rapport and develop the relationship.
  • Negotiate follow-up
  • Learn from the encounter by reviewing DSM IV
    criteria or other relevant resource.

34
After you BATHE SPEAK
  • Schedule each day
  • Pleasant activity each day
  • Exercise relaxation each day
  • Assert yourself
  • Kindness

35
Behavior Change Visit
  • Get background information on the problem
    behavior.
  • Assess readiness to change
  • Precontemplation
  • Contemplation
  • Preparation
  • Action
  • Maintenance
  • Relapse
  • Assess patients expectations and concerns. Build
    rapport and develop the relationship.
  • Set short and long term goals
  • Negotiate next step
  • Increase patients motivation to change
  • Reflect on patients barriers and your own
    lifestyle.

36
Leading Causes of Death in the United States in
2000
37
Actual Causes of Death in the US in 2000
38
NEWS FLASH
  • Most visits are mixed visits!
  • Remember to do your logs

39
Teaching at the Bedsire Sir William Osler, MD,
1849-1919
It is more important to know that patient that
has the disease than which disease the patient
has.
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