Facilitators Guide
Description: This guide is intended to help the faculty deliver this 60-minute discussion reviewing potential pervasive barriers to the delivery of high value care, providing tools for effective communication with patients and colleagues. This is the fifth in a series of six sessions.
Learning Objectives:
Understand the barriers to high value care in clinical practice
Explore ways to overcome barriers to high value care
Weigh the efficacy and safety of medical interventions to avoid inappropriate use and harm
Practice negotiating a care plan with the patient that incorporates their values and addresses their concerns.
Frame aneffective consult question
Explain the importance of managing the expectations of patients, residents, fellows and attendings in the consult setting
Audience/Setting: The intended audience for this module is internal medicine residents and faculty. Large group setting with time and space for small group work within the session is best.
Equipment Required: Computer with LCD projector for power point presentation, internet access to stream the videos in the module, speakers for audio and video clips, white board or flip chart for recording group work. Audience response -can be an electronic polling method, simple note cards, or simply a raising of hands. You may want to open the links to the two videos prior to the presentation, make sure they project appropriately, and minimize them to prevent technical difficulties.
Selected References:
1. Chou R et al. Diagnostic imaging for low back pain: advice for high-value health care from the ACP. Annals 2011. 154:181-9
2. Studdert DM et al. Defensive medicine among high-risk specialist physicians in a volatile malpractice environment. JAMA. 2005;293:2609-17
3. Ong S et al. Antibiotic use for emergency department patients with upper respiratory infections: prescribing practices, patient expectations, and patient satisfaction. Ann Emerg Med. 2007;50:213-20
4. Lee T, Pappius EM, Goldman L. Impact of inter-physician communication on the effectiveness of medical consultations. Am J Med. 1983;74:106-112.
Presentation #5 Instructions
Step / Description / Estimated Time1 / Welcome participants, introduce speaker, identify the reason for the discussion including:
· The importance of understanding barriers to high value care in order to overcome them
· Explain the learning objectives on slide 2 / 5 minutes
2 / Case 1 - Non-Specific Low Back Pain
· Emphasize that the patient presents asking for an MRI
· Slide #4 - Poll the audience and ask what they would do in this situation and why
· Slide# 5 - Briefly review ACP guidelines by playing video by clicking on the link behind the image (approx. 2 mins). Note that the video will open up in a separate window- hover over the picture and click on the full screen icon to enlarge. Note that MRIs are not recommended for non-specific low back pain since they do not improve outcomes (which are very good regardless) and may lead to more disability / 10 minutes
3 / Underlying causes of overuse
· Slide #6 - Point out that despite strong guidelines, physicians continue to order imaging in non-specific low back pain.
· Slide #7 - Discuss the list and point out that following up on test results can be time consuming. Have the group create a top five list for their local institution making the number one barrier the most important one.
· Slides# 8-9 - Discuss defensive medicine. Define it; talk about its prevalence; and use data to dispel the myth that ordering more tests protects doctors from law suits. Click on the microphone on slide #9 to play the audio clip (approx. 2 mins) of lawyer Lois Snyder discussing defensive medicine and malpractice
· Slides #10 - Discuss patient expectations and the process of talking to patients about not doing things. Emphasize that patients (unlike customers) are not always right and it is our ethical responsibility to explain to them why we are not giving them what they asked for.
· Slide #11 - Ask the group how they would discuss not doing tests with patients. Review the principles of patient-centered communication. (Note that many of these principles will be modeled in the video on the following slide)
· Slide #12 - Play the video displaying a physician talking to her patient about not getting an unnecessary imaging test by clicking on the link behind the image (approx. 3 mins). Note that the video will open up in a separate window- hover over the picture and click on the full screen icon to enlarge. / 15 minutes
4 / Case 2 - Sore Throat
· Slides #13-14 - Present the case and emphasize the conflict between what the patient wants and what you think is medically indicated
· Slide #15 - Divide participants into pairs or small groups to answer the questions and practice role-playing a discussion with this patient about her treatment plan.
· Slide #16 - Have groups vote on what they decided to do. Highlight why option B is not a good compromise: risk of potential harms for the patient (C. difficile, allergic reaction) and for society (antibiotic resistance), and reinforces the common belief that antibiotics are effective in viral URI’s. / 10 minutes
5 / · Discuss the challenges in the inpatient setting
· Slide #17 - Who is in charge when consultants are involved in patient care? How does co-management work in your institution?
· You may want to mention the AMA guidelines that state: “One physician is in charge of a patient’s care and that the attending physician has the overall responsibility for the patient’s treatment”. Furthermore, consultants should only advise and make recommendations on problems that are within their scope of practice
· Have the residents identify the challenges they experience in asking for or receiving consults in the hospital / 5 minutes
6 / Case 3 - Consultation for Swollen Knee
· Slides #19-20 - Discuss how to frame a good consult question. Rationale of why it is important / 10 minutes
7 / Wrap-up and summary
· Ask participants to commit to two thing they will start doing and two things they will stop to overcome barriers to high value care / 5 minutes
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