Medical Insurance - Teaching in the Hands of Patients and Their Families

Transcription

1 AUTHORS: Suresh Nagappan, MD, MSPH, Angela Hartsell, MD, MPH, and Nicole Chandler, MD Cone Health Pediatrics, Department of Pediatrics, University of North Carolina, Greensboro, North Carolina Address correspondence to Suresh Nagappan, MD, MSPH, Cone Health Pediatrics, Department of Pediatrics, University of North Carolina, 1200 North Elm St, Greensboro, NC Accepted for publication Feb 13, 2013 ABBREVIATIONS FCC family-centered care FCR family-centered rounds doi: /peds Teaching in a Family-Centered Care Model: The Exam Room as the Classroom To study the phenomenon of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all. Sir William Osler, 1903 Although Osler challenges us to study disease in the context of patients, family-centered care (FCC) challenges us to study disease in front of and alongside our patients. This article focuses on teaching in the presence of patients and families, at the bedside and during outpatient encounters, as part of the ongoing Council on Medical Student Education in Pediatrics series on skills and strategies used by superb clinical teachers. WHAT IS FCC? FCC is rooted in collaboration among patients, families, physicians (including those in training), and nurses. 1 It is guided by the principles of respecting the patient and family, building on each family s strengths, beingflexible, offering choices about care when possible, being transparent, and collaborating with families to make shared decisions. 1 Long before the term was coined in the second half of the 20th century, FCC was practiced by many pediatricians and family physicians. FCC in practice has decreased length of stay and readmission rates, 2 but benefits to learners have been less well documented. FCC is difficult to teach in a traditional classroom setting and is better demonstrated though role modeling and including learners in the partnership of care. One method of incorporating FCC into teaching is through family-centered rounds (FCR) or family-centered discussions both at the bedside and in the examination room. Sisterhen et al 3 defined FCR as interdisciplinary work rounds at the bedside in which the patient and family share in the control of the management plan as well as in the evaluation of the process itself. FCC with FCR provides an opportunity for learners to observe attending physicians bedside manner, physical examination techniques, and interactions with patients in both inpatient and outpatient settings. Preceptors can also directly observe students taking histories, examining patients, and counseling children and families, all of which are more effectively taught in the presence of a patient. By teaching at the bedside in the context of a real patient, students are more likely to receive immediate, relevant knowledge that will stick with them. Having role models who teach, and learn, in front of patients assists students in developing their own communication skills and bedside manner. 4 IN THE CLINIC A common concern of busy preceptors is finding the time to teach while running a hectic clinic. A study by Baker et al 5 in the clinic setting found that examination room presentations (in which the student presents the case in front of the patient, family, and preceptor in the examination room rather than to the preceptor alone outside the examination room) took a similar amount of time and resulted in higher patient satisfaction than conference room presentations. Anderson et al 6 showed that clinic patients who experienced examination room presentations by learners preferred this method when offered a choice for future visits. Teaching in an FCC environment also affords preceptors an opportunity to role model, and teach, different styles of communication. Although it is difficult to explain to a student how to be empathic or reassure a worried 836 NAGAPPAN et al

2 MONTHLY FEATURE parent or discuss a complex medical problem, it is possible to demonstrate these skills by talking to patients and families in the presence of students. In a 2008 focus group by Williams et al, 7 a medical student stated, It s very powerful if you see the example on an actual person, and especially if you know more about their story, their background, you re more likely to take something away from that experience, whether it be some kernel of knowledge about a disease or a certain way of interacting with patients. The family and the patient, when approached with respect, become an integral part of the teaching process. ON INPATIENT ROUNDS Teaching in an FCC environment is beneficial in the inpatient setting as well. A 2003 American Academy of Pediatrics policy statement recommended that FCR be standard practice. 8 Since then, FCR has become the predominant method by which inpatient rounds are conducted on pediatric wards around the country. 9 Although Muething et al 10 found that it took 20% longer for FCR in the inpatient setting, there were other time savings downstream, such as less frequent call backs to answer questions from families or nurses. With FCR, the student has the opportunity to practice effective ways of communicating with families by using understandable language, avoiding jargon, and involving families in the decisionmaking process. LEARNERS PERSPECTIVES Learners, though, are not convinced. Although 85% of patients prefer presentations in their rooms, only 53% of learners think that presenting in the presence of the family is more educational than conference room rounding. 11 In a randomized controlled trial, learners were significantly more comfortable asking questions (84% vs 69%) and being asked questions (85% vs 67%) when presenting in the conference room; only 4% of students felt comfortable presenting in front of families. 12 Wang-Cheng et al, 13 in a 1989 survey, found that 95% of residents preferred to do presentations away from the patient. Many reported a fear of looking foolish in front of a parent. This fear is especially acute in students, many of whom are struggling to develop their basic presentation skills. The additional task of trying to maintain rapport with families leads to added discomfort. In a focus group on FCR of students from the University of North Carolina rotating at Cone Health, a medical student noted, I think it s very hard to earn the respect of the patients and family as a student. I think giving constructive feedback to junior members of the team is easily and often misconstrued by families as a lack of confidence in those team members, which consequently makes it hard for families to trust their judgment. Although these concerns are valid, students do become more comfortable presenting in front of patients with practice and experience in FCR. 10,14 In Cox et al s 14 survey of medical students who had completed a 6-week pediatric clerkship that included presenting in front of patients, only 17% were concerned about being pimped. Many come to believe that teaching is more relevant during FCR and that they learn in ways that are not practical in the conference room. 10,15 TIPS FOR TEACHERS For FCR to succeed as an educational tool, these legitimate learner concerns need to be addressed. A resident in Williams et al s 7 focus group stated, If teachers can set the tone and what the expectations are and say that it is okay to make mistakes, we all make mistakes, but the great doctors are the ones who take those mistakes and use them to improve themselves, that s thebestwaytolearninthatstressful environment. The preceptor can set thetoneforasafelearningenvironment with the following practical steps: Set expectations at the beginning of the learner s rotation. Introduce the members of the health care team and acknowledge their level of training. Acknowledge to the learner the stress of presenting in front of patients and families along with the preceptor s goal of supporting the learner without humiliation. Give the learner permission to not know and ask for help. If a learner says something incorrectly or inappropriately, use positive reinforcement to acknowledge what was correct and then explain what the actual plan will be. Offer direct constructive feedback outside the patient s room. 4 Direct Socratic questioning to the group instead of an individual whenever possible. Teaching in an FCC environment does, however, have limitations. Some important discussions, such as reviewing extensive differential diagnoses or considering highly sensitive topics, such as abuse, may be better held outside the patient s room. CONCLUSIONS FCR in both inpatient and outpatient settings benefits patients and learners. It has the potential to assist in creating a supportive environment in which trainees learn by watching and listening to their attending physicians, by making mistakes and correcting them, and by connecting with patients and families. PEDIATRICS Volume 131, Number 5, May

3 ACKNOWLEDGMENTS We gratefully acknowledge Drs Janice Hanson, Robert Dudas, and Susan Bannister for their extensive comments and editing. REFERENCES 1. Committee on Hospital Care and Institute for Patient- and Family-Centered Care. Patient- and family-centered care and the pediatrician s role. Pediatrics. 2012;129(2): Forsythe P. New practices in the transitional care center improve outcomes for babies and their families. J Perinatol. 1998; 18(6 pt 2 suppl):s13 S17 3. Sisterhen LL, Blaszak RT, Woods MB, Smith CE. Defining family-centered rounds. Teach Learn Med. 2007;19(3): Young HN, Schumacher JB, Moreno MA, et al. Medical student self-efficacy with family-centered care during bedside rounds. Acad Med. 2012;87(6): Baker RC, Klein M, Samaan Z, Brinkman W. Exam room presentations and teaching in outpatient pediatrics: effects on visit duration and parent, attending physician, and resident perceptions. Ambul Pediatr. 2007;7 (5): Anderson RJ, Cyran E, Schilling L, et al. Outpatient case presentations in the conference room versus examination room: results from two randomized controlled trials. Am J Med. 2002;113(8): Williams KN, Ramani S, Fraser B, Orlander JD. Improving bedside teaching: findings from a focus group study of learners. Acad Med. 2008;83(3): Committee on Hospital Care. American Academy of Pediatrics. Family-centered care and the pediatrician s role. Pediatrics. 2003;112(3 pt 1): Mittal VS, Sigrest T, Ottolini MC, et al. Family-centered rounds on pediatric wards: a PRIS network survey of US and Canadian hospitalists. Pediatrics. 2010;126(1): Muething SE, Kotagal UR, Schoettker PJ, Gonzalez del Rey J, DeWitt TG. Family-centered bedside rounds: a new approach to patient care and teaching. Pediatrics. 2007;119(4): Gonzalo JD, Chuang CH, Huang G, Smith C. The return of bedside rounds: an educational intervention. J Gen Intern Med. 2010; 25(8): Landry MA, Lafrenaye S, Roy MC, Cyr CA. A randomized, controlled trial of bedside versus conference-room case presentation in a pediatric intensive care unit. Pediatrics. 2007;120(2): Wang-Cheng RM, Barnas GP, Sigmann P, Riendl PA, Young MJ. Bedside case presentations: why patients like them but learners don t. J Gen Intern Med. 1989;4(4): Cox ED, Schumacher JB, Young HN, Evans MD, Moreno MA, Sigrest TD. Medical student outcomes after family-centered bedside rounds. Acad Pediatr. 2011;11(5): Chauke HL, Pattinson RC. Ward rounds bedside or conference room? S Afr Med J. 2006;96(5): FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. FUNDING: No external funding. 838 NAGAPPAN et al

4 Teaching in a Family-Centered Care Model: The Exam Room as the Classroom Suresh Nagappan, Angela Hartsell and Nicole Chandler Pediatrics 2013;131;836; originally published online April 15, 2013; DOI: /peds Updated Information & Services References Citations Subspecialty Collections Permissions & Licensing Reprints including high resolution figures, can be found at: /content/131/5/836.full.html This article cites 15 articles, 5 of which can be accessed free at: /content/131/5/836.full.html#ref-list-1 This article has been cited by 1 HighWire-hosted articles: /content/131/5/836.full.html#related-urls This article, along with others on similar topics, appears in the following collection(s): Administration/Practice Management /cgi/collection/administration:practice_management_sub Quality Improvement /cgi/collection/quality_improvement_sub Standard of Care /cgi/collection/standard_of_care_sub Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: /site/misc/permissions.xhtml Information about ordering reprints can be found online: /site/misc/reprints.xhtml PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, Copyright 2013 by the American Academy of Pediatrics. All rights reserved. Print ISSN: Online ISSN:

5 Teaching in a Family-Centered Care Model: The Exam Room as the Classroom Suresh Nagappan, Angela Hartsell and Nicole Chandler Pediatrics 2013;131;836; originally published online April 15, 2013; DOI: /peds The online version of this article, along with updated information and services, is located on the World Wide Web at: /content/131/5/836.full.html PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, Copyright 2013 by the American Academy of Pediatrics. All rights reserved. Print ISSN: Online ISSN: