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__"

	Living	Learning	Working
Physical
Intellectual
Emotional
Spiritual

Direct Primary Care: Medical Student Track -- Office Based Competencies M1 & M2

The excitement about Direct Primary Care (DPC) is catching the attention of medical students. Unfortunately, curricular adjustments and faculty enthusiasm aren't keeping pace with the evolution of this solution.  One group to fill the educational void is the practicing DPC physician.  Another is organized medicine (yes). 

As I've written before, each level of medical learner has a different expected competency level regarding DPC.  The model I introduced in my February 4th blog is anchored by SPIT SOAP (for a way to remember a med student differential diagnosis: Serious Probable Interesting and Treatable and the Subjective, Objective, Assessment, Plan framework for the heart of the clinical note).

	Serious	Probable	Interesting	Treatable
Subjective
Objective
Assessment
Plan
Dx, Rx, Pt Ed

Medical Students LOVE differential diagnoses- clinical thinking.  They don't love it as much when faculty (including office based preceptors) use it against them to show what they don't know.  Understanding what can be expected of M1, M2, M3, and M4 should make it easier to facilitate their learning.  

A first year med student does little with the differential diagnosis in the clinical setting. They can do very well with the social and interpersonal skills, including the history of present illness.  From my Feb 4th post model: first years should also be able to get the identifying information (II), the chief complaint (CC).  Feb 4th Dr Synonymous post

"Identifying Information:  Age, Race/Ethnicity, Occupation, Living Associations/ Arrangements and Location, Major Recent Events or Expected Events (or Migration Narrative/Direction), Payment Method (and comfort with/understanding of/ confusion about)."

Notice that the II includes information that clarifies the uniqueness of the patient to the student AND enables the student to engage them briefly about their payment method.  ALL payment methods are associated with uncertainty these days (including DPC), which makes this part of the student - patient engagement enlightening for both.  The student will learn some things that the physician doesn't know about yet, enabling them to stimulate changes in patient education about their payment plan. DPC physicians know how challenging it is for patients and physicians to understand the beauty of the DPC office visit (or cyber followup) initially.

The M2 would be expected to have the M1 skills and be able to do a SPIT differential diagnosis at the level of systems and processes.  I give them a paper with a column of  systems (starting with Family) and a column of pathological processes to check off (the ones thought of by the student or mentioned by the patient).  After the encounter, before the presentation of the patient, they pick a SPIT (four of their checked items).

This M2 SPIT will be placed across the top of the SPIT SOAP grid as they posit the subjective and objective information needed to "drive the note" with the differential diagnosis at the level of systems and processes, not specific disease names.  I engage them about their thinking, mine and that of the patient.  Note how much time might be involved in this process.  In DPC, there is more than traditional practice.  I have a hybrid practice, so it's often half way between DPC and traditional (except, I do a "Families Only" practice and have a "slower" practice already- yes, I'm into genomics every day, too).

The M2 Assessment is expected as systems and/or processes (they may be advanced and get more specific with disease names)

I share my differential diagnosis over and over with students to help both of us.  They hear (see and feel) about the issues that are distracting from patient care with my traditional patients.  They  get to see, hear and feel about DPC issues, too.  The clinical and relational quality gap between traditional and DPC will grow as the non-system adds distractions from the patient-physician engagement.  The differences will be noted by the med students more and more.

Showing the pipeline of Family Medicine learners how much clinical thinking, human relating, fun and professional satisfaction go along with DPC is a job for DPC physicians first and foremost.

More M3 and M4 later.

What do you think?

Direct Primary Care: Office Based Teaching Model for Med Students

Medical Students in their first, second, third and fourth year of medical school should have different levels of expected competencies, which can be especially helpful in learning about Direct Primary Care (DPC).

In the clinical encounter, the elements of competency that I emphasize in my office-based teaching/ learning are: the Identifying Information, Chief Complaint, History of Present Illness, the Differential Diagnosis and the SOAP note.  DPC learning and understanding fit well into this model.

Identifying Information:  Age, Race/Ethnicity, Occupation, Living Associations/ Arrangements and Location, Major Recent Events or Expected Events (or Migration Direction), Payment Method (and comfort with/understanding of/ confusion about).

HOPI:  Patient's Starting Health status, Course, Onset, Duration, Intensity, Exacerbations, Remissions and associated Signs and Symptoms related to Chief Complaint.

	Serious	Probable	Interesting	Treatable
Subjective
Objective
Assessment
Plan
Dx, Rx, Pt Ed

Plan    Diagnostic    Therapeutic    Pt. Education

I discuss this model and its use at each level of medical student on The Dr Synonymous Show Feb 3, 2015. The Dr Synonymous Show