Medical Student Role on Family Centered Rounds (FCR)

Part 1:How to Succeed

Mary Ottolini MD, MPHVice Chair of Medical

Education

Overall Objectives For Successful

Presentations During FCR: Part 1 Objectives• Describe the purpose of FCR and your role.1. Use the ‘PBEAR’ format to give easy to follow, succinct oral

presentations • including only pertinent positive and negative findings

Part 2 Objectives (discussed in separate presentation)1. Begin a presentation on a new patient by representing the “Big

Picture” (Problem Representation)Identify the ‘defining features’

+ Use adjectives (‘semantic qualifiers’) to describe how you’re thinking= Combine into a ‘Problem Representation’

Part 3 Objectives (discussed in separate presentation)1. To use discriminating features to analyze the differential

diagnosis2. Describe the difference in the presentation for a new vs. an old

pt

Part 1 Objectives1. Describe the purpose of FCR and your role.

2. Use the ‘PBEAR’ format to give easy to follow, succinct oral presentations • including only pertinent positive and negative

findings

What is the purpose of FCR?

Please click on the video below to play:

Play Video

The Purpose of Rounds

1. Calibrate and Correct a Shared Mental Model

2. Create a Plan for the Day

3. Assign and Accomplish Tasks

4. Plan Transitions of Care

5. Educate Yourself and the Patient/Family

1. Calibrate and Correct a Shared Mental Model

Use (I) PBEAR (SS)• (I) Introductions and greeting

– Senior resident says hello- introduces team– Asks parent/patient what concerns them most today and

why?

• PBEAR– Use this structure for your case presentation – Communicate a clear thought process

• (S)olicit relevant input from staff/team members- – Senior Resident asks Nurse, Case Manager, patient and

parents

• (S)hare the team’s mental model with the family– Senior Resident Checks understanding – Asks about data that doesn’t fit

2. Create a Plan for the Day

• Based upon pertinent data (meds, studies, VS, overnight events)

• Assess progress and Anticipate likely problems

• Propose a Plan

• Validate and Verify the plan – Team members– Parents/patients

3. Assign and Accomplish Tasks

• Renew, refine or discontinue patient orders

• Jot down tasks to complete after rounds

4. Plan Transitions of Care

• Assess discharge/transfer criteria – Estimate the Timeline

• Identify specific transition needs – (wean O2, family teaching, referral to

rehab)

5. Educate Yourself and the Family

• Just-in-time and self directed learning:– Identify your gaps– Write down questions– Use your smart phone

to look up information

– Observe the Physical Exam

• Family integration and education: – Address concerns and confirm

comprehension

Learning During Family Centered Rounds

What makes it work?

Efficient Case Presentations

Don’t Repeat

See/Examine the Patient

Deliberately Multi-task: Look up information about the pt

during rounds

Efficient Presentations are Crucial to Your Learning!!Succinct, Clear Presentations

Changing the emphasis from:Data delivery -------- Data synthesisThoroughness-------- SelectivityAll the data ------ The pivotal data“Hx-heavy” ----------- “DDx-heavy”

Traditional Case Presentation

vs. PBEAR• CHIEF COMPLAINT

• HISTORY, PE; LAB

• ASSESSMENT

• PLAN

• P: PROBLEM– Represent the problem using

adjectives to communicate how you are thinking about the defining features of the problem

• B: BACKGROUND EVIDENCE– Report ONLY the key evidence

relating to the Dx/Rx of problem– Ask if more data is needed

• A: ANALYSIS– Analyze the differential-

Compare/contrast discriminating features/evidence to determine diagnosis

• R: RECOMMENDATION– Express uncertainty– Goals for management– The Plan– State what you are going to read

about

Communication Skills:

• Speak audibly/ clearly

• Avoid Digressing or Repeating

• Avoid Intermixing data where it doesn’t belong (i.e. PE findings during HPI)

• Use medical terms appropriately.

• Use notes appropriately

• Look parents in the eye-Be Sensitive to impact

Background Evidence:

• Background Evidence: Subjective (History) – Accurately synthesize the history

• Problem-focused with pertinent positives/ negatives.• Omit Irrelevant Data

– Logical progression of events- easy to follow

• Background Evidence: Objective Data: – Accurately synthesize the physical exam and lab

data. • Include problem-focused pertinent positives/ negatives

and pending data .

• Omit Irrelevant Data

Watch the Video and Assess: 1. Communication 2. Background Evidence

Please click on the video below to play:

Play Video

Communication Skills:

• Speaks audibly/ clearly • Uses medical terms appropriately. • Uses notes appropriately • Sensitive to impact on patient/ family.

Spoke inaudibly or unintelligible «------------------------------------------------------------» Spoke completely clearly and audibly.

Often digressed/ repeated. «------------------------------------------------------------» No repetition/ digression

Read or used notes inappropriately. «------------------------------------------------------------» Used notes completely appropriately.

Ignored patient/ family. «------------------------------------------------------------» Clearly Included patient/ family.

Intermixed data (ie history in PE) «------------------------------------------------------------» Presented all data in the correct category

X

X

X

His speech was audible, but with a lot of “uhms”

X

Notes should only be referred to for discrete data points- not read “Mom said she looked sick…No travel outside the country”-this is out of order/confusing

NA

Background Evidence:

Background Evidence: Subjective (History)

• Accurately synthesizes admitting/ interim history. • Problem-focused with pertinent positives/ negatives. • Logical progression of events.

Omitted most of the relevant data «------------------------------------------------------------» Included ALL the relevant data. Included irrelevant data. «------------------------------------------------------------» Omitted ALL the irrelevant data Confusing progression of events. «------------------------------------------------------------» Easy to follow progression of events.

•

XX

X

“NSVD- was discharged in 3 days…mother was unsure of GBS status”- this is irrelevant and confusing

Developmental Hx and Family History are irrelevant to the presenting problem

The cough should be described in more detail and in the HPI not ROS.The amount of intake and urine output should be described in greater detail to assess hydration.

Background Evidence: Objective Data:

Omitted most of the relevant data

«------------------------------------------------------» Included ALL the relevant data

Included irrelevant data «------------------------------------------------------» Omitted ALL the irrelevant data

Exam/ labs inaccurate/incorrect «----------------------- ------------------------------» Accurate/correct exam/ lab data

Comments:

X

No description of her overall appearance; no vital signs, inadequate pulmonary exam

Normal eye findings are irrelevant; get an Otoscope!

Don’t state details of normal and irrelevant lab values- ie U/A and Lytes

XX

In Summary…

Be prepared to discuss the following questions:1. Describe the 5 purposes of Family Centered

Rounds?

2. Explain PBEAR format for presenting.

3. What are the key attributes of good Communication?     

4. How do you determine what Background Evidence is pertinent to present on FCR?