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University of Malta Faculty of Medicine and Surgery Dept

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University of Malta Faculty of Medicine and Surgery Dept. of Family Medicine. The Community Assignment. This attachment will focus on the elements of the consultation and the communication skills required for good consulting. The contrast between hospital medicine and family practice will be seen as an opportunity to acquire the right perspective about illness in the community and the methods used to deal with it. The community assignment will enable the students to discuss (rather than simply describe) the process of care that is peculiar to the practice of Family Medicine. The assignment should be focused on a case or a small number of cases observed during the attachment. The case will be used to highlight all the relevant aims and objectives as described below. A 2000 word assignment is the maximum length allowed. Aims 1. To expose the student to holistic medicine in Family Medicine. 2. To highlight the patient’s perspective on the illness experience. 3. To expose the student to as many clinical skills as possible. 4. To encourage the student to interact with the patient and the Family Doctor. 5. To involve the student in the management plan and discuss the options available. Objectives: 1. To break down the consultation in different parts as per Calgary Cambridge Guide, see it in practice and recognize the flexibility a doctor has to be able to make 2. To observe the different methods of gaining the patient’s ideas, concerns and expectations (ICE) and incorporating these in negotiating a management plan. 3. To discuss how Family doctors deal with the number of complaints in each consultation, how these are prioritized and how doctors deal with the uncertainty of the clinical picture. 4. To understand continuity of care and the importance of record keeping. 5. To understand how the patient illness affects the family and the role of the Family Doctor. 6. To observe the practice of preventive medicine, identification of risk factors and the skills used for motivational change. 1 7. To be able to use sensitivity to gain insight on compliance with the prescribed medication and advice. 8. To use reflection at the end of the clinical attachment a) for teaching and learning purposes, a. for the choice of a case for their write up, b. for the discussion of differential diagnosis and management in Family Medicine. 9. Define and view the content and process of a consultation, the roles within it and advantages and disadvantages of the doctor-cantered and patient-centered approaches; 10. Seek further information about a particular condition and know how best to structure that information. 11. Understand the nature of diagnosis in family practice and the clinical reasoning skills used by Family Doctors. 12. Discuss the use basic clinical skills to diagnose many of the patient’s problems. 13. Plan a program of management that satisfies the doctors and patients agendas. 2 Family medicine community assignment Bader Ali MD IV group 3 The case: A 26-year-old mother presented with a complaint regarding her 12-year-old son, James. James was playing football when he injured his ankle. James twisted his ankle when another player from the opposite team tripped him. He cannot walk on it but can stand on the foot. There was only minimal swelling on the lateral aspect of the left foot with no bruising and minimal tenderness. The boy states that he was tripped while He complaints of 4 out of 10 on the pain score. There is no loss of sensation when touched over the affected foot. It should be added that the mother was clearly distressed and the patient was becoming anxious due to her stress. He suffers from no previous medical condition or has any allergies. But the mother states that he is not eating as much as he used and that his appetite is decreasing. Last year he had a similar injury with a confirmed fracture of the lateral malleolus, which was missed on initial examination by the GP at that time. James lives with his both his parents and his 2 younger sisters. The mother states that he is doing well in school and is not facing any major difficulties at home or school. After reassuring the mother that a fracture was highly unlikely and that most likely he has only a sprain. The management plan proposed involved reassurance, RICE and simple analgesia. However, the mother insisted on an X-ray. It was explained to her that the dose of radiation would not be necessaries but after she insisted it was agreed that the she would wait 2 days after which if the pain does not subsides the doctor would order an X-ray for her son. 2 [Type the document title] Before the first patient entered the consultation room during my first day on the family medicine attachment, the GP to whom I was attached told that family medicine is the art of gaining the patient trust, knowing what is going on with him, agree on a management plan and for the patient to leave satisfied in the consultant, all of that in under 15 minutes. When the mother and her son first entered the room it was clear that she anxious and distressed and that her son was being affected by her anxiety. The GP welcomed her, introduced his self and myself. When I thought about it I could see how much simple things such as introducing yourself, getting up to welcome the patient affects the doctor patient relationship and makes the patient more at ease and more likely to trust the doctor and open up. What I found very interesting that for the first 2 minutes the GP said not a single word but allowed the mother and her son to talk and explain what was going on with them. I realized that by doing this he gave the mother and her son the impression that he is here to listen and that he cares. He knew that she was anxious and worried about her son and needed someone to whom she can share her worries and concerns. It was great how while the GP was not saying anything his posture, eye contact and expressions where saying a lot to the patient and his mother. I could feel it from his non-verbal that he genuinely cares. I realized that within just 2 minutes the mother calmed down after venting her worries and that the GP has gained the patient and his mother attention by showing them that he is interested with what is going on with them. Initial impressions and good communication skills can make the difference between a bad consultation and a good one. Once the mother finished explaining to the doctor about her son injury and loss of appetite the doctor told the mother gently that he wanted to speak to her child and that he wishes to examine his leg. I was very impressed by how polite the doctor was and his politeness was diffusing the mother’s tension somehow. I also felt that by asking the mother that he wishes to speak to her son, he was both acknowledging her presence but also reconfirming that the patient is her son and that this consultation is about him. After examination is clear that a fracture was unlikely and that conservative management was only indicated. However, the mother informed the doctor that she wanted an X-ray. The GP was surprised by her request and reassured her that he does not think that it is necessary but the mother insisted. Once asked by the GP to why she is insisting she said that last year her son had a similar injury with a fracture but the GP at that time failed to recognize it and it caused her son great discomfort and she had to stop work to look after him. When I reflect upon it I realized that true reason for her visit was to request an X-ray and not to seek the GP advise. I realized just how past experiences of the patient affect the outcome of the consultation and how one bad experience could affect the patient decisions and behavior for a considerable time in the future. Bader Ali MD IV group 3 Furthermore, I realized how important it is to be able to understand the reasons behind the patient’s visit, in order to be able to know how best to help him. When I reflect upon it I could understand the reason while the mother was insisting on an Xray, as she trusted the X-ray more than the doctor. Although as a student I might say she was wrong, if I place myself in her shoes I would have probably have done the same. Moreover, it was clear that the percussions of the previous GP’s mistake was profound on this patient as she has to take time of work and this most likely lead to considerable stress on the mother and her family. It must feel disappointing to visit a doctor and trust his decisions and in the end his decisions were wrong and you had to suffer as a result. Even though this time it is a different doctor, I believe that once you have your trust broken it is more difficult to trust again. With that being said I realized just how much the family doctor can have an impact on the family’s quality of life and how much he can affect their daily lives. I also realized the role the GP plays in the community and his role in continuously education his or her patients. When the mother kept insisting on an X-ray the doctor told her that he would issue a request for an X-ray but in 2 days time. If by then the pain goes away or subsides it would be evident that there is no fracture and he would cancel the request and in doing so save her son from unnecessary radiations. When I think about it I realize that the compromise that was reached was a very good one, as the doctor didn’t take and X-ray but did not deny it completely to the mother. The doctor understood the mother’s worries and saw no point in loosing her trust by denying her completely and that she would most likely go to see another doctor but by thoroughly explaining his position and reaching a compromise he insured that his consultation would be a good one for both himself and the patient. The GP concluded the consultation and reaffirming his management plan and making sure that the mother and her son have no other questions and are satisfied with the plan. During this consultation I realized just how important the role of the family doctor is in influencing the daily lives of his patients and the impact he or she might have on the lives of their patients. On looking back I believe that it was a successful consultation. On the other hand, there might be some room for improvement, For example the doctor could have gone in more depth to the reasons behind the patients anxiety and in such way would have been able to help both the mother and the her son. He might also have been able to refer the mother for psychological support. Discussing possible methods of future prevention could have been discussed. When reflecting back I believe that I gained valuable insight in management plan negotiation techniques through the various ways to reaching compromise and reaching a settlement. I have also gained knowledge on different ways on how to get information from patients through allowing then talking and gaining their trust. 4 [Type the document title] Also I realized how uncertainty is a fact in family medicine and that the doctor has to really on his clinical skills and experience to make an informed decision. It is important to realize also that mistakes do happen and to appreciate their repercussions. Moreover, Family medicine practice forms an important part of the community hence the importance of establishing good doctor patient relationship and to continue monitoring and reviewing patients and the establishment of a “safety net” to ensure the patient safety and well-being is always the top priority. To summaries through simply observing his consultation I strongly believe that I have gained more insight into the practice of family medicine and also a better appreciation how uncertainty is a fact with the practice and the different ways and means practitioners use to over come this and the methods they use to ultimately result in a successful consultation. Bader Ali MD IV group 3 ? Libertarian vs. egalitarian. ? Who is an expert? ? Is the weather worse? ? Are people too rational? ? ? What are the stakes of disagreement? Us. Vs. Them. “If you are one of us, believe this; otherwise we’ll know you’re one of them.” Dan Kahan, Nature (2012) ? ? ? Dan Kahan, Cultural Cognition Project “Belief” does not reflect knowledge, but rather expresses identity. No correlation between numeracy and belief. Most knowledgeable are the most polarized. Dan Kahan, et. al. Nature Climate Change, 2012 ? ? ? In liberal societies, it is mostly easy to converge on scientific facts. Toxic partisan meanings associated with climate change. Political actors (on both sides – not really a false equivalency). Dan Kahan, Cultural Cognition Project, Yale University ? ? ? ? ? Southeast Florida Regional Climate Action Plan Monroe County Board of Commissioners – 4 democrats, 3 republicans. Monroe County, Broward County, Miami-Dade County, Palm Beach County. Facilitating science informed public deliberations and provide a model for what evidence based scientific communication looks like. Start with the concrete and go from there. Southeast Florida Regional Climate Change Compact 12:15 < Notes Case 2 59 Women comes in with dog bite (rottwhiler) 2 days ago she has been seen previously, sutured and given antibiotics -She has numbness (on hand and forearm) -swelling -Cannot close hand -Tingling -Pins and needles -No fever -Was given tetanus shot and augmentin (antibiotic)but did not resolve so when she came to the clinic she required more antibiotics Drug history and medical history: -She takes aspirin , dypyridamol both (75mg) -Hypothyroidism: levothyroxine -Has previously Broken her ankle - (plate inserted surgically) -Had cataract surgery done -No allergies In the clinic: -When dr briefly touched her hand she was in extreme pain -He marked the redness and swelling with a pen to see if it increased further 12:15 < Notes In the clinic: -When dr briefly touched her hand she was in extreme pain -He marked the redness and swelling with a pen to see if it increased further -he asked her if she was in a lot of pain and she was he asked her if she has transport or not Asked her if she needed painkillers (paracetamol) Gave her referral ticket to emergency department - She claimed that she would not be able to go to work so he immediately got sick leave papers to write her a sick leave form and said that will leave it open and valid for 2 weeks Told the other nurse to kindly put a sling and change to a clean dressing He reassured her that it would get better with the antibiotics for sure and that he would like to see her daily until the swelling subsides. He wanted to see her until the swelling went as was worried of compartment syndrome (mention about compartment syndrome and dangers and why doctor would be worried)