Author Archives: mspin

Introduction to Systems Improvements (AIM Statements)

Activity

These IHI modules are optional – IHI online open school.  Supplementary activity to provide greater detail and context for the material covered in lecture.  Recommended for students pursing a certificate in quality and safety. Improve understanding of aim statement by providing additional examples.

IHI Online Open School Modules – http://app.ihi.org/lms/home.aspx

  • QI 101 Lessons 1- 3 (optional) – Examine the six aims of quality health care and the principles of improvement science.
    • This supplementary activity will describe the aims of quality health care and the principles of improvement science.
  • QI 102 Lessons 1- 2 (optional) – Identify the steps in the model for improvement and the components of a quality improvement aim statement.
    • This supplementary activity will provide greater detail and context regarding setting an aim statement for quality improvement work.

Interrupting Bias

Required:

Stroke

Objectives

1. Work with the concepts of life course and exposure and susceptibility in relation to risk of having and surviving a cerebral vascular accident, with potentials for good or bad outcomes when there is class, racial, gender, or geographic inequality
2. Discuss potential stroke prevention interventions at different stages of the life course and different levels of the social-ecological model, taking into account class, racial, gender or geographic inequality

Why this topic:
It is important to recognize that over the course of one’s life there are exposures that can put someone at advantage or disadvantage regarding health risks. This is true for stroke. What are the upstream exposures? How can we explain these exposures and their health consequences to others including our patients?

Before class: (what is written below is also in a word doc version)

1. Review risk factors for stroke at link (Links to an external site.)Links to an external site..
2. Explore the CDC website: Interactive Atlas of Heart Disease and Stroke (Links to an external site.)Links to an external site.

  Think about the following questions:

  • How does the WWAMI compare to the rest of the country with regards to stroke prevalence and death from stroke?
  • What does the prevalence of stroke look like in your Foundations WWAMI state?
  • When looking at your WWAMI state, are there disparities among individual counties?
  • Are there risk factors, social and economic characteristics, health behaviors, or access to care measures that you find surprising for your Foundations state and its individual counties? Use data and filter options to see disparities within individual counties.

3. Read the “Future Directions” section (pages 887-888) pdf which is extracted from Harvanek et al. Social Determinants of Risk and Outcomes for Cardiovascular Disease: A Scientific Statement From the American Heart Association Circulation 2015  (Links to an external site.)Links to an external site.(link for those who want to read the entire article) about social determinants of health and their impact on cardiovascular disease. Cardiovascular disease risk is often used as a surrogate for stroke risk.

4. Come to class prepared to think about influences on a person’s risk of having a stroke (remember that the impact is multi-factorial) and be prepared to discuss the article. In particular, how might physicians communicate inequities within risk factors that lead to disparities for strokes and their outcomes.

5. Read Perzynski et al., Informing Policy for Reducing Stroke Health Disparities from the Experience of African American Male Stroke Survivors 2015 and think about how one can improve stroke health disparities as a society and as an individual physician.

In Class

Stroke SDH PowerPoint

During the session you will be divided into smaller groups. Each of small groups will be provided with a clinical vignette highlighting a patient diagnosed with a stroke. Keep the following concepts in mind.

1. Over a life course there are various pathways to health and disease.
2. There are effects of exposures, with cumulative interplay and effects.

Working as a groups and using the Social Ecological Model, give examples of the pathways and exposures that might have advantaged or disadvantaged the patient described in the clinical vignette. One member from your group will type out your group’s thoughts into a public Google spreadsheet. Specifics for using the spreadsheet will be given in class. Consider these questions:

  • What elements of the individual’s history suggest possible positive and negative pathways and exposures?
  • If you were to write the fictional (but realistic) story of the individual’s life, what other possible positive and negative pathways and exposures can you think of? Do NOT stereotype the individual. DO think of the complex interplay of factors throughout the life course, and the influence of factors at all levels of the social ecological model. Use the case as a sketch, and paint the rest of the picture.
  • What factors, if present in the case, or worth exploring, might have put this person at increased risk for stroke?
  • What factors might influence the likelihood of surviving the stroke?

 

Cultural Context of Pain

Objectives

  1. Recognize and discuss factors leading to pain treatment challenges, variability, and access due to race, gender, ethnic, social and economic disparity
  2. Describe unique pain assessment and management needs of special populations
  3. Describe the role of the clinician as an advocate in assisting patients to meet treatment goals
  4. Explain how health promotion and self-management strategies are important to the management of pain
  5. Describe patient, provider, and system factors that can facilitate or interfere with effective pain assessment and management
  6. Design an individualized pain management plan that integrates the perspectives of patients, their social support systems, and health care providers in the context of available resources
  7. Reflect on the wider role of the clinician, within and beyond the healthcare system, as an advocate for patients suffering from chronic pain
  8. Describe the impact of pain on society

Before Class

1. Required reading

After reading the articles, write a short reflection that includes the following, and upload it to the pre-class quiz on Canvas.
For each article:

What is one finding in each article which surprised you? Why?
What is one thing you have a question about?
How and where will you seek answers to your questions?
One of the studies noted in the first article mentioned that some Native patients have an ‘expectation of empathy.’ The Native patients “expressed the conviction that it was the provider’s role to perceive and experience the patient’s pain in order to treat it” without the patient having to describe their pain in detail. What do you think about this? Do you believe this is possible across cultural beliefs and practices? Why or why not?

2. Required videos

Some questions to ponder as you watch:

In the field of medicine you are particularly interested in, how might historical trauma express itself in a patient’s life? What would be some possible physical, psychological or emotional manifestations?
Do you think historical trauma is different or the same as social determinants of health?

  • Interview with Chaplain Joisky Caudill: An Indigenous Perspective on Health and Wellness (12 min) 

    Some questions to ponder as you watch:
    How did Chaplain Joisky negotiate her care with her physicians? As a provider, how might you offer opportunities for your patients to negotiate their treatment with you? What would you do, say or ask?

Some questions to ponder as you watch:
What are ‘positive’ stereotypes about Native Americans/Alaska Natives? Why are they harmful?
What is your reaction when you hear Chaplain JoiSky’s definitions of medicine and health?  How would you know if your patients defined these concepts differently than you do? Why might that be important to be aware of?

There is mention that some Native people may understand illness and pain as manifestations of sickness of soul or as something which happens as a result of something a person was meant to do but hasn’t done. How would you work with patients who hold beliefs such as these? Would their beliefs change how you would provide care for them?

‘Racial Disparities in Pain Medication Use’ (10 min)

Review from EHM Cultural Humility Film (first 12 of 15 min) 

Historical Trauma: Hozhonahaslíí: Stories of Healing the Soul Wound Part III (11 min)

In Class

Students will work in small groups to discuss the case story with a community consultant.
Small groups should designate a member to write up a brief summary of their discussion with guest consultant (please include in your summary who your guest was, and the names of the people in your group).

The summary should include
1. One thing which was surprising to hear or was a new perspective
2. Two points of information you will carry forward as a future physician

We will reconvene as a large group for report out.

Please sign in for attendance of small group.

After Class

Healing the Warrior’s Heart 

 

Ethics of Brain Death

Objectives

1. Articulate the ethical issues that arise in the determination of brain death
2. Identify and discuss physicians’ ethical and professional duties when, due to religious, cultural or other reasons, a patient’s family does not recognize brain death and insists on continued medical intervention after declaration of brain death
3. Identify and discuss physicians’ ethical and professional responsibilities when, due to religious, cultural or other reasons, medical providers or medical institutions insist on continued medical intervention after declaration of brain death

Review these Key Terms:

Read:

These two articles discuss the ethics terms above in greater detail and help us to apply them in the case of brain death. As you read these articles, consider how our cultural norms and ascriptions might affect our ethical judgments and reasoning. Note the discrepancy between our use of ‘cultural’ ascriptions to patients and to the medical profession.

 

Review the 4-Box Method and Complete the blank worksheet for each of the below cases…

CASE 1:  J

16-year-old (pronouns she/her) with a history of depression and ADHD who presents with coma. She was diagnosed with depression when she was 13 and had never attempted suicide before. Her parents are divorced and barely on speaking terms. She was at her mother’s place, talked to her father on the phone, who sent her grandparents to get her from her mother’s place. She had gotten into an argument with her mother about playing a video game. She was then found hung with a taekwondo belt around her neck tied to the bedpost. CPR was initiated by the mother. EMS found her to be in PEA arrest. She was given epinephrine. Circulation returned, but she was thereafter non-responsive. She was intubated and transferred to the ICU for care.

Over the next two days, she does not respond to painful stimuli or voice; does not grimace to pain; has no gag reflex; has no limb movements to pain; pupils are fixed and dilated; no spontaneous respirations; no volitional activity.

After she loses all brainstem reflexes, an apnea test is performed.  It confirms the absence of a respiratory drive when the patient is allowed to accumulate COwithout artificial ventilation.  A second brain death examination is needed per institutional policy, and is performed 24 hours later, confirming whole brain death.

The patient’s physicians in the ICU, palliative care, and neurology teams have been preparing the mother and father and their families for this possibility.

The neurologist explains that she has died and asks if they would like to have time with her before the ventilator is removed.  Her dad replies, “She’s warm. Her heart is beating. She’s breathing.  She’s not dead. We want a second opinion.  There must be more tests you can do.  She’s in there somewhere.  As long as she’s breathing, her soul has not left her body.”

While some religious traditions do not recognize brain death, her family simply genuinely believes she is not dead.  In their view, withdrawing the ventilator would cause her death, so when the time comes to extubate, they throw themselves over her body and say they will not let anyone ‘stop any of the machines’.

*Pulseless electrical activity or PEA refers to a clinical diagnosis of cardiac arrest in which a heart rhythm is observed on the electrocardiogram that should be producing a pulse, but is not.

Consider:

  • What might hamper the clinician-patient/family relationships in this case?
  • How ought healthcare providers respond to this situation? What steps should they take and why (use the concepts of relational autonomy, beneficence/non-maleficence, virtue, etc. to guide you)?

 

CASE 2: Marlise Munoz:

“Marlise Muñoz was 33 years old and the mother of a 15-month-old when she collapsed on November 26, 2013, from what was later determined to be a massive pulmonary embolism. Initially described as apneic but alive, she was brought to the county hospital where her family was soon told that she was brain dead. Ms. Muñoz and her husband, both emergency medical technicians (EMTs), had discussed their feelings about such situations. So Erik Muñoz felt confident in asserting that his wife would not want continued support. Her other family members agreed, and they requested withdrawal of ventilation and other measures sustaining her body’s function.

In most circumstances, this tragic case would have ended there, but Marlise was 14 weeks pregnant and lived in Fort Worth, Texas. Texas law states that a “person may not withhold cardiopulmonary resuscitation or certain other life-sustaining treatment designated . . . under this subchapter (the Texas advance directive law) . . . from a person known . . . to be pregnant.”1 The hospital caring for Ms. Muñoz interpreted this exception as compelling them to provide continued support and declined the family’s request to end such interventions. The attorney representing the hospital indicated that the law was meant to “protect the unborn child against the wishes of a decision maker who would terminate the child’s life along with the mother’s.” After weeks of discussion and media attention with the hospital remaining intransigent, Mr. Muñoz sued in state court to have his wife’s and family’s wishes respected.”

From: Ecker, J. Death in Pregnancy—An American Tragedy, NEJM, 2014, http://www.nejm.org/doi/full/10.1056/NEJMp1400969#t=article.

FIND A MORE ON THE CASE HERE: http://www.npr.org/sections/health-shots/2014/01/28/267759687/the-strange-case-of-marlise-munoz-and-john-peter-smith-hospital

Consider:

  • What might hamper the clinician-patient/family relationships in this case?
  • How ought healthcare providers respond to this situation? What steps should they take and why (use the concepts of relational autonomy, beneficence/non-maleficence, virtue, etc. to guide you)?

 

Optional Further Investigation:

 

Reflection

Metacognition: Thinking about thinking; Knowing about knowing; Being aware of your awareness.
  • It is a self-regulatory process that monitors and evaluates your own cognitive processes.
  • Metacognitive practices help you identify your own strengths, weakness and limitations so that you can identify strategies to expand your knowledge or skill level.
Reflection is a metacognitive process that occurs before, during and after situations with the purpose of developing greater understanding of both the self and the situation so that future encounters with the situation are informed from previous encounters. (Sandars, 2009)
  • We do not learn from our experiences by simply having them.
  • Reflection on action allows us to gain understanding and learning from the experiences we have had.
  • The Adult Learning Cycle by Kolb (1984) is one way to conceptualize the steps we take to learn from our experiences. Reflection on action is a key piece.

Figure 1. The adult learning cycle by Kolb. Courtesy of www.infed.org/biblio/b-explrn.htm.

Steps in Adult Learning Cycle:

  1. You have an experience.
  2. You reflect back on that experience. You may identify actions you took or reactions you had and the consequences or outcomes.
  3. You analyze and try to understand why you took those actions and/or where the reactions came. You hypothesize about  how they led to the consequences.  You think about how you may apply these concepts to other situations and identify any learning needs you may have to close a gap in your knowledge or skills.
  4. You plan how what you will do next time you are in a similar situation based on your conclusions from Stage 3.

Example 1:

  1. You take an exam assessing your knowledge of cardiovascular drugs and receive a score below what you expected.
  2. You reflect on your study strategy which included making flash cards to test yourself on the mechanism of action, half-life and side effects of each medication. The test, however, required you to select appropriate drugs based on clinical scenarios.
  3. While you are confident with the pharmacokinetics and the mechanism of action of the medications you think you might not have gained a deeper understanding of the down stream effects on the patient’s physiology. You think that understanding drugs at this level will likely be applicable to other systems, as well.
  4. You make a plan that next time you lean about a drug you will consider how the medication will affect physiology and what the down stream effects may be. You will also identify clinical problems that would be treated or managed by these effects.

 

Example 2:

  1. You are taking a history from a teenage girl. During the social history portion, you ask her if she has a boyfriend. She crosses her arms, becomes quiet and participates minimally in the rest of the interview.
  2. You reflect on the conversation and identify that her behavior and engagement changed when you asked her about the boyfriend. You also recalled that you did not inquire whether she had romantic or sexual relationships with females and wonder if she felt isolated or judged after asking only about male “boyfriend-type” relationships.
  3. You hypothesize that some people may feel uncomfortable answering closed ended questions with limited presented options. You consider that you may be applying your own or other societal norms to your questions that may feel alienating to the patient.
  4. You make a plan that next time you are taking a social history, you ask open-ended questions when inquiring about sexual orientation, gender identity, relationships and family structure.
Practical Tips

  • Consider implementing a self-reflection process into your educational routine.
  • One quick method is using the Plus-Minus-Delta model.  After an experience, ask yourself 3 questions:
    1.     What went well? (Knowledge, behavior or skill)
    2.     What could be improved upon?
    3.     What will I do differently next time?
  • To gain a deeper understanding add a “Why?” between each step.

 

Supplemental Reading:

Sandars J. The use of reflection in medical education: AMEE Guide No. 44.  Medical Teacher. 2009;31:685-695.

Other references:

Kolb, D. A. (1984). Experiential learning: Experience as the source of learning and development (Vol. 1). Englewood Cliffs, NJ: Prentice-Hall.

IPE: Teamwork and Values

Teamwork and Values Conflicts

  1. We share core professional values but sometimes our values conflict with those of another (perfectly reasonable) team member. The training and practice of an occupational therapist emphasizes safety, which was in direct conflict with patient autonomy in this specific patient case.
  2. Conflicting opinions are a normal part of working in teams.  Successful teams a) assume positive intent, b) listen to each other, c) make sure every person on the team expresses their view, and d) concludes conflicts by negotiating a plan for next step/s.
  3. Place the patient at the center of the team.  Understanding the patient’s perspective on health and healthcare places the patient at the center of the team’s conversation, and can help all team members get behind a plan that meets the patient’s needs.
  4. Listening and speaking up are critical team skills.  Listen as much (or more) than you speak.  But speaking up is important for all team members to share their concerns or new information.
  5. We can’t always be the hero.  Sometimes we can’t “save” a patient. When we have different goals or health beliefs than a patient, we may not always feel good about our what we are able to do (allowed to do) for a patient or the patient’s outcome.
  6. Don’t take it personally.  When you feel challenged by a patient, ask other team members how it’s going for them. Don’t assume you’re the problem, or are the only one having difficulty.  If you’re frustrated, it’s likely others on the team are too.
  7. Talk to your team first.  When you feel challenged by a patient, don’t go it alone. Use your team to help you problem solve. Difficult patients can split us as teams. Knowing other’s roles and responsibilities and using them to full potential can share the burden of high maintenance patients.
  8. Think broadly when you think “team”.  Physicians, nurses, pharmacists and social workers practice in close proximity, often rounding together, but other team members may not be in the loop.  Remember to include everyone in challenging care decisions.
  9. Support your team members.  Especially when we have a challenging patient, we need to rely on and trust our team members to do their jobs.  Work together to adopt a common approach.

Challenging Patient Interactions

  1. “Difficult” interactions:  Challenging behavior or interactions are often a sign that, from the patient’s perspective, their needs aren’t being met.
  2. Engaging patients:  Exploring patient’s preferences in a non-judgmental way is key to enhancing motivation and engagement, both of which are essential to effective care.
  3. Respect for patient autonomy:  Ultimately, patients make their own decisions. The challenge for providers is to take the journey with them, work creatively to bridge medical aims and patient priorities, and provide support.

Interprofessional Education

Interprofessional collaboration is a core skill for all clinicians and is a required accreditation element for medical, nursing, pharmacy, physician assistant, and social work program. The competency framework developed by the Interprofessional Education Collaborative outlines four domains for education and practice in team based care:

  • Values and Ethics for Interprofessional Practice: Work with individuals of other professions to maintain a climate of mutual respect and shared values.
  • Roles and Responsibilities: Use the knowledge of one’s own role and those of other professions to appropriately assess and address the health care needs of patients and to promote and advance the health of populations.
  • Interprofessional Communication: Communicate with patients, families, communities, and professionals in health and other fields in a responsive and responsible manner that supports a team approach to the promotion and maintenance of health and the prevention and treatment of disease.
  • Teams and Teamwork: Apply relationship-building values and the principles of team dynamics to perform effectively in different team roles to plan, deliver, and evaluate patient/population- centered care and population health programs and policies that are safe, timely, efficient, effective, and equitable.