Tuesday, February 17, 2015

Direct Primary Care-Office Based Competencies for Medical Students- Intensity of HOPI

Expanding a bit on my posts about DPC and Office Based teaching, I'll clarify an element of the History of Present Illness (HOPI).

The Identifying information begins a dialog with the patient that prepares the student for the context of the HOPI.  In Family Medicine, context is critical (everything?).

The HOPI discussion starts with contextual insights about the patient, but the SOAP written note usually begins with the state of the patient's health at the onset of the Chief Complaint (CC).  Next is the patient's narrative about the CC, including the course, onset, duration, intensity, exacerbations and remissions, and associated symptoms.  (CODIERS)  This is basically an X and Y axis of time versus amount of negative symptoms.

The intensity element (I) is critical to clarifying the impact of the illness/episode on the patients context.  I use a model derived from Robert Carkhuff, PhD (Helping and Human Relations, The Art of Helping, etc.) with the addition of a spiritual element to discern intensity.  Larry Bauer MSW, MEd and I have used this model for over thirty years with learners at many different levels.   This helps both patient and student during values exploration (PIES- left column) and impact on major elements of the patients life (LLW).  For example, if the patient slips on the ice and strikes their head, sustaining a concussion and neck and head pain resulting in difficulty with short term memory, concentration and sleep, and their context is- college student with two term papers and a mid-term exam coming soon,  they could have problems in physical living and learning as well as intellectual living and learning.  Further exploration during the student patient engagement would clarify other aspects of impact.

The information gleaned in clarifying the intensity of impact on values and contexts enables the student and patient to identify the patients deficit(s).  Clarifying the deficit(s) using the grid with the patient then enables the student and patient to establish the goal of the engagement.  A summary statement of the deficit/ goal may be in a form such as "You feel  __A____ because you cannot ____B_____ and you would like to be able to _____B__"





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