MED 1: Introduction to Clinical Medicine Bambam2017

UST-FMS Batch 2017 Section D [a.m.f.v] 1

INTRODUCTION TO CLINICAL MEDICINE Source: UST-FMS Medicine 1 Lectures 2014-2015 (by Dr. Moral), Mosby’s Guide to Physical Examination 6th Edition, Sheep Notes

“There is no more difficult art to acquire than the art of observation, and for some men it is quite as difficult to record an observation in brief and plain language.” “Variability is the law of life; and as no two faces are the same, so no two bodies are alike, and no two individuals react alike and behave alike under the abnormal conditions which we know as disease.”

- William Osler, M.D.

Our main goal here is to introduce you how to start talking to an individual. There must have a very good way of introducing yourself. First Patient Encounter

1. Establish rapport with patient 2. Get a clinical Hx (history)

“Story” – evolving process “History” – collection of past events connected to something or someone, series of events, may give you a possible outcome

3. Do a comprehensive PE (physical exam) 4. Formulate an initial Dx (diagnosis)

Differential Diagnosis 5. Plan for diagnostic and therapeutic action

As future doctors, what we need are the following: The Art and Science of Communication

Curiosity o Knowledge o Allows you to get information from

your patients Compassion

o Allows you to demonstrate caring for the patient and concern

o Interpersonal skills to respond to patients’ feelings and concerns

“Human existence depends on compassion and curiosity. Curiosity without compassion is inhuman, compassion without curiosity is ineffectual.”

- Victor Weisskopf Remember: Cornerstone of getting a good diagnosis is getting a proper history (70% of diagnosis).

BASIC CLINICAL SKILLS

History 70% diagnosis +

PE 90% diagnosis +

Expensive Tests confirm history & PE The skills necessary to perform H & PE are the foundation of clinical practice and should be considered part of basic science of medicine. (Video Showing of a Sample Interview) BENCHMARKS FOR MEDICAL STUDENTS THE TARGETED PROFESSIONAL VALUES ALTRUISM – unselfish concern for others

Put patient’s needs ahead of you o You end your history early despite the

fact that you’ve only completed the Hx because the patient “expresses too much fatigue” to continue

Be an advocate for individual patients o You “seek out the nurse” to ask her

about the patients’ pain medications because he appears to be increasingly in pain

Learn about social issues that impact the health of patients

o You research and read about the local services available for homeless patients after interviewing one

HONOR AND INTEGRITY – being honest, uprightness of character (honor) and adherence to strict moral or ethical code (integrity) Those who cheat in medical school have a higher incidence of cases filed against them. Honor and integrity starts early.

Be honest about who you are and about your experience level

o You introduce yourself as a “second year medical student”

o But if the patient refuses to be interviewed by a medical student, say “I’m Dr. _____, getting my M.D. in 2017.”

Accurately report data that you have personally verified

o You report the BP values you personally took

o Wrong: “Mukhang 120/80 naman sya eh.” or “Amoy 120/80, smells like normal.” LOL

o Honesty: “Dr, I think you gave me a grade for something I didn’t do.”

Admit mistakes and errors

Art and Science of Medicine

Patient Physician

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Make appropriate attribution to sources of ideas and data

o You put references/sources such as books/journals in your discussions

Be honest about your shortcomings o “I wasn’t able to do the report because I

watched a movie last night” NOT because your dog died or any lie.

CARE, COMPASSION AND COMMUNICATION

Genuineness – ability to be yourself in a relationship despite your professional role

o If your patient gives you a joke that’s really funny, then laugh.

o Express regrets like if the patient’s husband died.

RESPECT Has to be shown in order for you to get the same thing.

1. Introduce yourself to patient 2. Explain your role

“I know this has been done to you before (the interview), but we might get new data that will help your case.” The data you obtained may not have been gotten by previous interviewers.

3. Shake hands, but don’t force physical contact if patient is uncomfortable Personal space is culture dependent

4. Call the adult patient Mr., Mrs. (do not use first name) “Kamusta na po si Lolo?” , turns out she is a Lola. Be sure of your patient’s gender.

5. Maintain privacy “Ha? Naka 6 sexual partners po kayo?”, don’t, never never say this out loud.

6. Keep doors and curtains closed 7. Acknowledge and greet others in the room 8. Maintain a professional appearance

The patient might be conservative. No tank top and shorts. Wear doctor’s gown. Have a nameplate. The patient may not remember your name and say, “Ah, kayo ung matabang doctor na nagrounds kanina.”

9. Appear interested and ready to listen 10. Make sure the patient is comfortable.

Sit at the patient’s level. Stay on the right side as much as possible. Imagine the patient lying down and when he opens his eyes, he sees you hovering above them.

11. Be aware of personal space Don’t lean in too much. Baka mayakis na itsura nyo. Maintain eye contact but don’t stare.

12. Proper posture

S: sit square to the patient O: open to the patient L: lean in E: eye contact R: relax

RESPONSIBILITY & ACCOUNTABILITY EXCELLENCE & SCHOLARSHIP LEADERSHIP Having the patients apply what we teach to them. EMPATHY – the ability to understand the patient’s experiences and feelings accurately as well as to demonstrate that understanding to the patient

Objectivity, Precision, Reproducibility Pathophysiology and Clinical Epidemiology and

Treatment Human Behavior, Social and Cultural Contexts

EMPATHY Science (Diagnosis of disease) Art (Therapeutic relationship)

Empathy requires listening. Remain silent and let the patient talk.

Let the patient tell his/her story for 2 MINUTES, then you can start interrupting.

Silence can be helpful, don’t be afraid of it Baka naman 5 minutes na yung silence, parang shutter na yan. Huwag too much silence.

Use open-ended questions. Use “continuers” and echoing.

Continuers: Say “Go on..”, “Hmm..”, “Yes.” Echoing: Repeating what your patient says.

Interrupt only if necessary.

“Realize as far as you can the mental state of the patient, enter into his feelings, scan gently his thought. The kindly the word, the cheerful the greeting, the sympathetic the look – these patient understands.”

- William Osler THE MEDICAL INTERVIEW

Physician-centered Patient-centered Biomedical focus Gathers data Search diagnosis

Symptom focus Tells story Search meaning

It should be a patient-centered interview. Setting of interview

Comfort Remove all physical barriers (charts) Privacy – ask permission if you want to record

interview, assure that it is kept confidential. Good lighting Relative quiet Unobstrusive access to a clock – Stop looking at

your wristwatch while the patient is talking

Ability to ask common-sense questions should be there. For example, in TV interviews. Kapag nagcrash ung plane. Ung nagiinterview, iaask pa nya ung namatayan, “Ano pong nararamdaman nyo ngayon?”

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Purpose of Interview

Establish rapport Invite patient to tell story Establish agenda for interview Expand and clarify while testing hypothesis

(ung diagnosis mo) Create a shared understanding of the problem Negotiate for evaluation and treatment Educate the patient Plan for follow-up and thank them and close the

interview

Opening the interview

Greet the patient by name and shake hands. Ask the patient to sit down. Introduce yourself (as a medical student). Explain the purpose of interview. Say how much time is available

“Let’s try what we can do for the next 15 minutes or so.”

Explain the need to take notes and ask if acceptable.

(MEDIBABBLE – developed by medical students, translates different language (international). This is a free app.) Medical interview proper

Maintain a positive atmosphere (warm manner). Maintain good eye contact (but don’t stare at the

patient). Use open-ended questions at the beginning.

Gradually, try to be more specific. Listen carefully. Be alert and responsive to verbal and nonverbal

cues. Facilitate the patient both verbally and

nonverbally. Use specific (yes or no) questions as you go by. Clarify what the patient told you.

Filipinos: 40% will not ask for clarification.

When taking histories, note which are the signs (tenderness) and symptoms (pain). Also, tackle one complain at a time. Think of a funnel as you proceed with your interview, start wide with open-ended questions and gradually narrow your focus. What you need: ACTIVE LISTENING

Gather and retain information accurately Understand implications for the patient Respond verbally and nonverbally Demonstrate that you are paying attention and

trying to understand

Be careful also of your nonverbal expressions. My favorite story was when I was a senior resident, I was in ER. Around 3 in the morning, a patient came in and he looked like he was intoxicated. Then, my eyebrow lifted like about 2 mm. My face is very expressive, eh. Unfortunately, the patient saw this and ask, “Bakit mo ako tinataasan ng kilay?”. And for the next three hours, he was chasing me with a pencil poking it at my face. Although, he apologized naman after. From that time on, pinagpapantay ko na talaga kilay ko. What to watch out for: NONVERBAL CUES

Eye-contact – patient may feel embarrassed, depressed or uninterested

Posture – patient may sit upright, or slouched Gestures – angry patient (clenched fists),

anxious patient (taps finger continuously) Facial Expression – sad, angry, happy The way the voice is used – tone and timing

Ending the interview

Thank the patient for his/her time. Note: If you end early on, you may fail to

uncover critical information.

PARTS OF THE HISTORY

1. General Data (though Hx really starts at CC) 2. Chief Complaint (CC) 3. History of Present Illness (HPI) 4. Past Medical History (PMH) 5. Family History (FH) 6. Personal and Social History (PSH) 7. Review of Systems (ROS)

While taking History:

Don’t be judgmental. If possible, throw all your biases out the door. Be flexible. Avoid medical jargon. Avoid leading questions. Try to identify what the patient already know.

They will say like, “My survival is 10%. According to the Mayo Clinic....”

General (Essential) Data

Name of the patient Age Gender Civil Status Occupation Race Residence Religion

Chief Complaint – “Bakit ko kayo pumunta ngayon?”

Why the patient seeks care? If the symptoms become totally unbearable

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Anxiety about what the symptoms mean Something that they are embarrassed of or unaware of You should also be aware of local terms. “Doc, nagblow po ako. (vomiting)” Pula, in certain areas is yellow (pula ng itlog). Confusion, in bisaya is libog.

In life crisis

History of Present Illness (HPI)

Elaborate the chief complaint must be in chronological order General things specific things Tackle also pertinent negatives Avoid compound questions. Ask one at a time. From chief complaint;

o Location? o Quality? o Radiation? o Severity? o Time of onset? o Alleviating factors o Aggravating factors o Associated symptoms o Impact on lifestyle o Medications being used

PAST MEDICAL Hx

All medical problems that occurred beyond the time range of HPI

Also in chronologic order o Immunizations? o Illnesses before? o Surgical procedures?

FAMILY Hx

Gives you idea on what needs to be monitored Genogram/ Pedigree chart

o Cause of death o Health status of family members

PERSONAL AND SOCIAL Hx

Smoking Hx (pack-years) Alcohol Hx Environment (ventilation, preferences, etc.) Sexual Hx

REVIEW OF SYSTEMS

Any symptoms that have been experienced in the same duration of the HPI, but is included in other systems

The best teaching is that taught by the patient himself.

- William Osler, M.D.

MOSBY’s FUN FACTS (Chapter 1: The History and Interviewing Process) Knowing YOURSELF The first step in achieving positive relationships with your patients is to come to a good understanding of yourself. PARTNERSHIP with PATIENT Goals of the interview include the following:

Discovery – info that leads to appropriate assessment and care

Sharing – provide patient with information Negotiation – arriving at a joint course that

respects your patient’s feelings, needs and life situation

Union – establish joint effort in all aspects of care during sickness and health

Support – boost emotional and spiritual needs

ETHICS OF PARTNERSHIP with PATIENT

1. Autonomy 2. Beneficence 3. Non-maleficence 4. Utilitarianism 5. Fairness and justice 6. Deontological imperatives

THE VARIETIES OF CARE

ALLOPATHY – used to describe routine health and medical care offered in US and Western world; defined as “cure by inducing a pathologic reaction antagonistic to the disease being treated”

COMPLEMENTARY/ALTERNATIVE CARE – Eastern tradition, basic concept is “wholeness” or the unity of physical, emotional and spiritual within each of us

Basic Requirements of HEALTHY Communication

1. FLEXIBILITY a. Start with “open-ended” questions. b. Later, as information accumulates, ask

more specific questions to acquire precise and measurable details.

c. Open-endedness cannot be allowed to go on forever.

2. SPECIFICITY Types of Questions:

1. Open-ended question = gives patient discretion about the extent of answer “What are you feeling about this?”

2. Direct question = specific information “Where does it hurt?”

3. Leading question = most risky “It seems to be that bothered you a lot. Is that true?”

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As an interviewer, you can perform the following functions if the patient doesn’t understand what you are asking.

Facilitate – encourage patient to say more, either with your words or with a silence to allow patient to talk and reflect

Reflect – repeat what you heard to know more details

Clarify – “What do you mean?” Empathize – show understanding and

acceptance; say “I understand” or “I’m sorry” Interpret – confirm the meaning of what you

heard by repeating with your own words

3. CLARITY a. Define any words that are not

understood b. Avoid using medical jargon c. Meet the level of your patient’s

understanding d. Be sensitive e. Avoid leading questions

4. SUBTLETY

a. Choose your words carefully b. Ask appropriate questions c. For e.g. Most people think that “tumor”

is synonymous with “cancer”

5. EMPATHY a. Understand the patient’s experiences

and attitudes

MOMENTS OF TENSION There may be moments of tension during an interview when your patient exhibits the following:

1. Curiosity about You 2. Anxiety 3. Silence 4. Depression 5. Crying 6. Manipulation 7. Physical and Emotional Intimacy 8. Compassionate Moments 9. Seduction 10. Anger 11. Dissembling 12. Need for Money

HISTORY TAKING Structure of the History

1. Chief Complaint (CC) 2. History of Present Illness (HPI) 3. Past Medical History (PMH) 4. Family History (FH) 5. Personal and Social History (PSH) 6. Review of Systems (ROS)

AN APPROACH TO SENSITIVE ISSUES Privacy is essential.

1. ALCOHOL Questionnaires that may be used: CAGE by Erwing (1984)

Cutting Down Annoyance by criticism Guilty feeling Eye-openers

TACE Model – for pregnant women Take (how many drinks?) Annoy Cut down Eye-opener

CRAFFT – for adolescents Car (with someone who’s drunk) Relax (by drinking) Alone (drinking) Forget (stuff while using alcohol) Family member/Friend (who tell you to

cut down drinking) Trouble (from drinking problems)

2. DOMESTIC VIOLENCE

HITS Questionnaire Hurt Insult Threaten Scream

3. SPIRITUALITY

Approaching the Spiritual: FICA Faith, Belief, Meaning Importance and Influence Community Address/Action in Care

4. SEXUAL HISTORY

Address feelings, rather than facts. “Are you satisfied with your sexual life,

or do you have worries or concerns? Most people do have some.”

Use “partner” (a non-gender term)

5. SEXUAL ORIENTATION Reassuring, nonjudgmental words may

help: “I’m glad you trusted me.” Use “gender-neutral” questions.

Ung mga gray, kwento ni Dr. Moral, hehe. Ung mga violet na quotes, minsan lumalabas sa exam yan. So tandaan nyo na rin para sure. Ung mga professional values, laging lumalabas yan. Tandaan nyo differences ng respect at integrity. For e.g. kapag “introduce yourself as medical student”, integrity un. Kapag “introduce yourself” lang, pwedeng respect na un. Mosby’s Fun Facts fun facts lang, sa mga ayaw magbasa ng Mosby’s. Di lalabas sa exam (pero malay mo)