Rima Jubran

ACMD 512

Final assignment

Format: One session out of the Humanism and Professionalism curriculum for Hematology/Oncology fellows at CHLA: The Difficult patient

Learners: First year pediatric Hematology/Oncology fellows

Background and Purpose: Humanism and professionalism are integral to the practice of medicine, but explicit teaching of these principles is uncommon in the graduate medical setting. Definitions of humanism and professionalism in medicine are largely overlapping and include qualities of compassion, empathy, respect, accountability, responsiveness to the needs of patients and society and the commitment to ethical principles. More importantly the teaching of professionalism is a requirement of the ACGME.

Medical students are known to develop deep compassion and empathy for their patients and curricula in medical school foster this process. However there is wide concern that graduate medical education fails to preserve such humanistic attributes. The residency training experience presents trainees with many challenges including long work hours, high patient acuity, personal sacrifices, all of which conspire to suppress compassion and empathy. The first year of Hematology/Oncology fellowship is challenging as well. Fellows begin the year feeling powerless again and face many challenges including more personal sacrifice, longer work hours, higher patient acuity with the added responsibility of supervising residents.  They struggle with work life balance and are at risk for depression and burnout.

We will develop a case based fellow discussion curriculum with the aim to support fellows and allow them time to reflect on various aspects of humanism and professionalism inherent to being a doctor. Our hope is that they will generate strategies and coping skills to apply to their work.

Planned topics:

• ·         Delivering bad news
• ·         Medical errors
• ·         Work life balance
• ·         Difficult patients
• ·         Depression and burnout
• ·         Cultural sensitivity/competency

Anticipated challenges: Ensuring uninterrupted protected time for session attendance. We will reinforce the needs for protected time for the fellows with the nursing staff on the ward and in clinic to minimize interruption. Making sure the sessions are not used as a gripping session about systems issues in the hospital but to focus on supporting each other in the system as it exists. The facilitators will have to redirect the flow of conversation if the need arises. Finally reinforcement of confidentiality and respect/support of other participants will be emphasized in July every year.

References:

1-      American Academy of Pediatrics, Committee on Bioethics. Professionalism in pediatrics: statement of principles. Pediatrics 2007: 120; 895-897.

2-      ACGME Outcomes project. Http://www.acgme.org/outcome.

3-      Branch WT Jr, Hafler JP, Pels RJ. Medical students’ development of empathetic understanding of their patients. Academic Medicien 1998;73: 360-3.

4-      Hundert EM, Hafferty F, Christakis D. Characteristics of the informal curriculum and trainees’ ethical choices. Academic Medicine 1996;71: 624-42.

5-      Fahrenkopf A, Sectish T, Barger L, et al. Rates of medical errors among depressed and burnt out residents: prospective cohort study. BMJ 2008; 336: 488-491.

This session will focus on the Difficult Patient

The session description: Fellows read the preselected article Taking care of the hateful patient prior to attending the session. During the session one fellow will read aloud a case highlighting one of many challenges of communicating and interacting with a difficult patient or parent. The case will be used as a reflective trigger for discussion and several questions will be made available for guidance. The session is facilitated by selected faculty.  Fellows will write a self-reflection after the session describing an encounter they had with a difficult patient or parent which will be included in their portfolios. Feedback will be collected from the fellows after the session.

Session objectives:

After participation in the session, the fellows should be better able to:

1. Value the importance of empathy and respect in patient care
2. Reflect as a group on fellow experiences with difficult patients or parents.
3. Discuss factors contributing to “difficult” behaviors in patients or their parents.
4. Discuss strategies in which fellows can provide the best care for these patients, given time constraints and personal frustrations.

Instructional materials:

Pre-session reading material: Groves JE. Taking care of the hateful patient. NEJM 1978;298: 883-887.

Case vignette and questions for discussion handed out to all fellows and facilitators.

Time schedule:

00:00-00:15 Session introduction and discussion of the article.

00:15-00:20 Reading of Difficult Patient case

00:20-00:55 Group discussion and reflection

00:55-01:00 Session summary and instructions for self-reflection exercise

Process:

1-      Session introduction (15 minutes) with outline of what to expect during the session. Discussion of pre assigned reading.

2-      Reading of Difficult patient case (5 minutes)

3-      Group discussion and reflection (35 minutes). The fellow participants will discuss what went wrong and come up with suggestions to improve the interaction.  Fellows will put themselves in the patient and parents’ shoes and describe factors contributing to difficult behavior in patients or parents. One facilitator will write down the suggestions on the white board and expand the discussion on points of empathy, compassion, limit setting and focus on big picture.

4-      Session summary (5 minutes). Summary of take home points and instructions for self-reflection exercise.

Difficult patient case vignette:

The difficult patient

                You are the fellow on hematology service and you feel a rush of dread when you hear that Tyler Jones is coming in.  Tyler is a 16 year-old boy with sickle cell anemia, and a well-known “frequent flyer” on the ward.  This is the second time in two weeks that he has been admitted.

                Tyler is notoriously noncompliant.  He does not take his hydroxyurea and regularly smokes cigarettes.  During his last admission, he lost his IV and refused any further IV attempts, and then moaned with pain for the next several hours because oral medications weren’t helping.  You finally discharged him a few days ago and felt relieved to get him off your service.  Now, your attending tells you that his outpatient pain med prescription was never filled and he is back with severe vaso-occlusive pain.

When you arrive at Tyler’s room for your assessment, he is alone.  His mother was with him in the ED, but had to return home to care for her other children.  Tyler is alert, and his pain seems controlled, but he communicates only in monosyllables.  He stares at the TV, does not make eye contact, and is uncooperative with your exam.  His lungs sound clear and his oxygen saturation is 97% but you caution him to use his incentive spirometer since he has a history of acute chest syndrome.  As he flips through TV channels, Tyler says that he really doesn’t feel like talking to you right now, and asks if you can leave.  Frustrated, you say goodbye and exit his room.

                When you return to work on the morning, you hear from the residents that Tyler’s oxygen saturation has just dropped down to 91%.  You stop in to examine him before rounds.  He is curled up in bed playing a video game and responds to your questions only with brief grunts.  His nurse notes that he has been refusing to use his incentive spirometer.

                After rounds, you find out that Tyler’s chest x-ray shows a new infiltrate, and with the team, you decide to initiate treatment for acute chest syndrome.  As you supervise the residents, you feel angry and defeated, but try to push these feelings aside so you can deal with the many other patients on your list.

Questions for discussion:

1. How does this fellow’s  experience compare with experiences you have had in the hospital?  What are your memorable “difficult patient” stories?
2. What is it about Tyler that makes him a “difficult patient?”  To what extent does his personality play a role?  Can you think of outside forces that may also be contributing?
3. How might you approach Tyler’s management during this admission?  Who could you ask for help?  As a fellow, can you do anything to address the “big picture” of his illness, including his noncompliance?
4. What is the personal impact of dealing with patients like Tyler?  What feelings do difficulty patients trigger in you?

Teaching strategies:

Attention grabber: Pre-reading assignment 

Catalyst: Group-refection and facilitated discussion

Intensifier: Written self-reflection

Learner assessments:

Evaluation of written self-reflection and feedback given to individual fellow- portfolio entry

Facilitators will evaluate fellow involvement in the discussion using a rating scale

Session assessment:

Feedback from fellows and facilitators on pre-assigned article, the case and the discussion