500 - Teaching High Value Care, Orienting New Learners, Natural Medicine

From the Alliance for Academic Internal Medicine 

1)  Teaching High Value Care in the Clinical Setting 

Most medical schools have adopted a health systems science curriculum which folds many important “para-clinical” domains together: value-based care, informatics, ethics, healthcare financing, population health, etc. Teaching these important topics involves a diverse team of expertise, but a particular role for practicing clinicians is teaching “high-value care” (HVC) at the critical moment of deciding on a management plan for a patient. The concept of HVC requires an understanding of benefits (health, function, quality of life, etc.) and costs (which may include money, time, adverse events, etc.). In a clinical encounter, to deliver HVC, we must emphasize tests and treatments supported by evidence and cognizant of costs, avoid low-value care (care that is ineffective or harmful), and attend to patients’ values and preferences. 

The authors of a (pre-pandemic) project on teaching this concept created a multi-center study on teaching HVC during the clinical encounter using a “SOAP-V” presentation. Students are instructed to present a typical SOAP presentation but also to include a justification of the value of their management plans: 1) the research evidence behind their decisions, 2) whether their testing choices would change the management of the patient, 3) the alignment of their plan with the patient’s values, and 4) the relative cost of their plan.  

Third year students on internal medicine clerkships all got a single lecture in HVC, but ½ were chosen (non-randomly) to get additional supports: an additional lecture on the SOAP-V presentations, role-playing opportunities, a handout, support from a website about healthcare costs, and a video illustrating a SOAP-V presentation. The authors did not provide any instruction to the faculty or residents on the team. As outcomes, they measured self-efficacy in applying HVC and asked students about HVC discussions on rounds. They also conducted focus groups with students in two of the settings. 

Two hundred sixty-five students participated. One of the sites reported a higher number of students in the intervention group having received cost-consciousness training in medical school, but otherwise the groups were relatively similar. The students in the SOAP-V group improved their self-efficacy in having value discussions with their team and with patients. The control students did not change from baseline, except for a decrease in their self-efficacy of accessing cost information resources. In focus groups, students felt they were more comfortable with cost and risk discussions and with finding information about costs to share with their teams.  

The authors conclude that the SOAP-V framework is effective and practice for teaching HVC. 

John’s Comments:

As educational research, this study is “ok.” Change in self-efficacy is an important first step educational outcome, and this doesn’t seem to do any harm, but there are several methodological limitations. The number of resources applied to teaching HVC (vs the control group) almost guaranteed the outcome seen since it was measured by subjective assessments. Don’t let the study detract from the importance of the overall topic, however. We have the responsibility as clinicians to practice and teach this way – especially given the challenges of our modern healthcare environment. SOAP-V is an easy-to-implement addition to our clinical teaching inventory – maybe with 1-2 patients per session – so that our students understand the importance of high-value care in our work.  

Reference:  

·         Moser EM, Fazio SB, Packer CD, et al. SOAP to SOAP-V: A New Paradigm for Teaching Students High Value Care. The American Journal of Medicine. 2017;130(11):1331-1336.e2. Link

From Teaching Physician

2) Orienting a Learner and Optimizing the Learning Environment 

The start of the new “academic year” in medical education will soon be arriving, ad with it, the arrival of the “new learner.”  Whether a new student or a new resident, first impressions are important -- the first day of a new learner’s rotation with you sets the foundation for their entire experience, so here are some helpful reminders that can make their experience, and yours, much more effective and enjoyable. 

Before the learner arrives, be sure they know where to park and how to access the building.  Also, have someone send out an email to your colleagues and clinic staff announcing their arrival with a few fun facts: what school or town they are from, what they do for fun, personal motto, picture if you have one, etc.

When they arrive, be sure to meet with them to outline proper expectations and introduce the team and the clinical space.  Beyond getting to know one another, helpful agenda topics for this first meeting are: outlining one another’s expectations, setting avenues for feedback, and reviewing goals.  If they will be working with more than one clinician, be sure that there is agreement among the group as to these.

Outlining expectations:

●     Together, review the evaluation forms you need to fill out at the end of the rotation for their school/program. This way, you both are aware of any specific educational needs or requirements. This will also help you both understand how the learner will be evaluated.

●     Review any office policies that are relevant.

●     Define the level of involvement that is expected with patients, the anticipated patient load, and when they should involve you.  

●     Let the learner know the characteristics of the patient population your office sees.

●     Discuss guidelines and expectations for documentation and presentations.

Setting avenues for feedback:

●     How often will feedback be given? How should the learner give you feedback?

●     In what settings will it be offered? Real-time, one-on-one, mid-point meetings?

●     What is your feedback style? This is a great time to talk about your supervisory style with the learner.

●     Are there any times where it is inappropriate for the learner to ask questions?

Reviewing goals:

●     Talk through their goals to ensure they know what they will and will not have the opportunity to do and to be certain their goals are reasonable for the rotation. 

●     Ask if they are comfortable sharing these goals with the other clinicians and staff they may be working with and share accordingly.

●     If you have goals as an educator, share those with them and ask for feedback.

In the clinical setting, time is the most cited barrier to teaching. When a learner begins the rotation, it is important to have a process for integrating teaching into your clinical workflow.  In trying to optimize that learning time, it is recommended to reflect on the learner’s impact on the office flow prior to their arrival.

Consider the following as you manage the clinic workflow:

●     Patient and staff perspectives of the learner/their abilities

●     How to identify patients who may not want a learner present and how to manage that interaction appropriately

●     The amount of time will you allot before going into the room to confirm the history

●     How many patients the learner will see each session (ideally)

●     Structure of the day (it’s a good idea to meet with the learner and staff in the morning to review)

●     Specific aspects of patient care that would provide opportune learning experiences

Mark’s Comments:  

As you consider your workplace setting, it is important to keep in mind that the learner is consistently entering new learning environments.  For many, this can be overwhelming and exhausting.  A setting that is welcoming, well-organized, and has clear expectations relieves much of that anxiety and allows for more trust to be built between the learner and the preceptor.  The clinical learning environment is powerful - it provides a unique and valuable set of opportunities for instruction that a classroom cannot.  Keep that thought top of mind as you consider your role in the learner’s medical education.  My thanks to Hannah Lindsay, MEd, who created the first iteration of this Pointer.

Of note, I’m hearing from more and more colleagues regarding the challenges of regularly hosting medical students due to the increasing demands and busyness of practice.  In a future Pointer, we’ll consider these challenges and provide tips as to how one might host a learner in a way that is both “doable” and “enjoyable” in 2023, and beyond. 

References:

·         Modified from Teaching Physician. Orienting a Learner. Society of Teachers of Family Medicine. Retrieved from:  Link

·         Heidenreich C, Lye P, Simpson D, Lourich M. The search for effective and efficient ambulatory teaching methods through the literature. Pediatrics. 

2000;105(Supplement 2):231-7. Link

From PeerRxMed ( www.PeerRxMed.org )

3)  Is It Time to Start Regularly Taking Natural Medicine?

“Time in nature is not leisure time; it's an essential investment in our children’s health (and also, by the way, in our own).”  ― Richard Louv, Author and Journalist

Do you take regular time outdoors to intentionally connect with the natural world?  This might be through gardening, yardwork, walking (sometimes called forest bathing), camping, birdwatching, fishing, boating, or hunting. 

When I was a boy, our home backed to a farm, and I spent many a day playing in the woods, the fields, and the creek for hours until I heard the dinner bell.  My parents instilled in me a deep appreciation for the outdoors and modeled this by taking our family on camping, canoeing, and hiking trips.  I have carried this appreciation throughout my life, most recently in the form of standup paddleboarding, which I do regularly year-round.  When I am paddling, I routinely experience a feeling of presence, connection, and inner peace that is profound.   Indeed, those times on the water are my “Soul medicine.”

For many, such connection with the outdoors is becoming more of the exception, if it ever existed at all.  In his 2005 book The Last Child in the Woods, author Richard Louv coined the phrase “Nature-Deficit Disorder” to describe the negative impact on both children and adults of our increasing alienation from the natural world.  He described the costs to include attention difficulties, dulling of the senses, increased physical and emotional illnesses, a rising rate of myopia, obesity, and vitamin D deficiency. 

In the poem “The Peace of Wild Things,” poet, author and farmer Wendell Berry aptly and powerfully captures the “medicinal” qualities of spending time in nature. 

The Peace of Wild Things

When despair for the world grows in me
and I wake in the night at the least sound
in fear of what my life and my children’s lives may be,
I go and lie down where the wood drake
rests in his beauty on the water, and the great heron feeds.
I come into the peace of wild things
who do not tax their lives with forethought
of grief. I come into the presence of still water.
And I feel above me the day-blind stars
waiting with their light. For a time
I rest in the grace of the world, and am free.

So for this week, consider making a commitment to get outside in a more natural setting at least 15 minutes daily for the expressed purpose of simply being present and “noticing” through your senses.  Allow yourself to lay down any despair you might be experiencing and rest for a moment in the peace of wild things.  Not only will this help eliminate any “NDD” you might be experiencing, it is also my hope that it might serve as some “Soul medicine” for you – naturally.

______________

Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org