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Multidisciplinary Collaboration Improves Patient Care

5.1 Understand the institutions and individuals that participate in healthcare delivery and role of the physicians in the health care system.

Over the last few years, there have been several national trends in health care including reorganizing primary care into a patient centered medical home (PCMH). At these PCMH many different health care workers come together to provide comprehensive care. During my third year Family Medicine rotation at Lewis Center, I had the opportunity to work in a PCMH and interact with many different health care professionals who helped with patient care. In particular, they had care coordinators, medical assistants, nurses, social workers, counselors, behavioral health specialists, physical therapists, xray technicians, lab staff, and pharmacists. By interacting with these various individuals involved in patient care I learned more about each of their roles, and how multidisciplinary collaboration can improve patient outcomes.

There was one particular patient encounter at the Lewis Center Family Medicine Clinic that illustrated how a multidisciplinary team can improve patient care. This patient was a 65 y/o male who was found to be in a-fib on EKG. Our plan was to prescribe the patient a DOAC (eliquis) for anticoagulation because his schedule didn’t allow him to go in for frequent INR monitoring. Unfortunately, we  didn’t pay attention to the patient’s insurance or what anticoagulation medications that his pharmacy carries. The pharmacist caught this mistake and informed us that by sending the patient home on xarelto ($25 per month) vs eliquis ($149 per month), we could save the patient a lot of money. This medication change most likely increased the probability that the patient was able to purchase his medications and consistently take it. In the future, one of my goals is to pay more attention to insurance status and ensure that my treatments are the most cost efficient therapy for that patient. This could even mean calling pharmacies to inquire on drug prices to satisfy this goal.

I also learned a lot from my interactions with the care coordinators. While working with them, they taught me about the importance of identifying how the patient transports his/herself. This information is essential to helping link patients with necessary resources, and coordinating care so that a patient can see multiple providers with one visit. They also taught me that I need to pay attention to the patient’s work schedule before ordering fasting lab work so that they can fit it into their schedule. We also talked about how MDs should anticipate patient’s needs and allocate sufficient time for each visit to improve work flow. Allocating a complex patient to a regular time slot, will back up the entire clinic and prevent ancillary staff from doing their jobs on time. These teaching points are lessons that I want to incorporate into my future practice.

After learning these lessons in my clinical years, I was able to utilize my understanding of the various individuals involved in patient care to improve the no-show rate in an outpatient orthopaedic hand center as a part of our HSIQ project. Our initial baseline data showed that 26% of patients missed their routine post-op appointment, and 65% of patients incorrectly believed that they had completed follow up. In order to address this we completed a prioritization matrix (shown below) which identified that automated calls, AVS dot phrases that pulled up next appointment dates for patients discharged from the ED, and office staff identifying patients who no showed and sending this list to central scheduling as well as the surgeon were the most beneficial interventions. As a result, we worked very closely with the medical assistants, physician assistants, and office managers to keep a detailed excel document of every patient who didn’t show up to clinic. Our group was then able to call the patients who didn’t show up and help them make an appointment. This project highlighted how working together with the many individuals who help take care of patients in the office can improve health care outcomes. As an intern I hope to continue to learn from the various health care members to improve my practice. I especially want to work closely with social work and PT to coordinate care for my post-op patients.

Artifact 1: Prioritization matrix and root cause analysis for my HSIQ project

Physician Well Being Paramount to Ensure Patient Safety.

6.2 Demonstrate responsiveness to patient needs that supersedes self-interest

As an aspiring surgeon, I love to be in the OR and enjoy seeing the dramatic impact that a surgery can have on a patient’s life. I knew that surgical complications occurred in practice, albeit rare, and were associated with significant morbidity for patients. However, it wasn’t until my third year general surgery rotation where I got to witness the significant impact that a surgical complication had not only on the patient, but also on the surgeon and his team.

During my third year, I had the opportunity to spend a month on the surgical oncology team. During a morbidity and mortality conference that month, we discussed a routine thyroidectomy for thyroid cancer which was complicated by cutting the recurrent laryngeal nerve. The resident presenting recalled that they protected what they believed was the recurrent laryngeal nerve and proceeded with the surgery. Post-op they found that the patient had trouble speaking and his symptoms were consistent with a transection of his recurrent laryngeal nerve.

Later that day, I was paired up with a surgeon performing several thyroidectomies and parathyroidectomies. The first case was going very well, and we were making excellent progress. About half way through the case, progress slowed considerably and we spent an extensive amount of time identifying the landmarks and neurovascular structures. There was extensive discussion between the resident and attending before every move. Near the end of the case, I noticed that the surgeon was crying through his mask. He later explained that he was crying  tears of joy. At this point, I was very confused but I didn’t have the courage to question what was going on.

 

Once the attending left the room, I found out that this was the surgeon who had that complication of cutting the recurrent laryngeal nerve that was presented at the morbidity and mortality conference. This was his first thyroidectomy since that complication. At that moment, I could understand the emotions that the surgeon was feeling and why he was overwhelmed with emotion at the end of the case.

 

This case brought up several teaching points for me. Was this surgeon in the proper mental state to perform this case? Should I or others in the room have spoken up? What resources are available for surgeons going through this? This was a case that I have spent considerable time discussing with my portfolio coach and with my friends to discuss what I would have done if I was the surgeon performing the case. After this reflection, I came up with several teaching points that I hope to carry for the rest of my life. I know that despite my best efforts, at some point in my surgical career I will run into a devastating patient complication and I must develop skills to handle it. This year I have worked hard to talk more openly about my emotions and confide in others to help me work through difficult situations. I have included a screenshot of text messages in my text messaging group of my best friends (who all are going into orthopaedics) where we talk about stressful moments (such as submitting our rank list this week). I have also made time for my hobbies and friends to destress as well (which is captured in this reflection post). In the future, one of my goals is to debrief with my peers after such incidents so that I can process what just happened and identify if there is anything else that I could have done differently. I also learned that the most important thing is patient safety, and I should not perform any procedure where I am emotionally, physically or mentally comprised in any way. I hope to be more introspective in the future to identify instances where I may not be in the appropriate state to operate, and take time off in the interest of patient safety. In this way the patient’s needs will always supersede my own self interests.

Artifact 1:Group chat with peers going into ortho to debrief about challenges of the application process and to talk about our rank lists. 

Artifact 2:Reflection post highlighting new strategies to prioritize my mental health. 

This case highlighted the devastating consequences that can occur with any surgery. This experience and the subsequent internal reflection has allowed me to develop proper channels to destress, identify resources in the community, and ultimately become more resilient. As a professional I must hold myself to the highest standards to ensure patient safety.

 

 

Impact of Diversity and Social Determinants of Health on Health Care Delivery.

4.2 Understand how human diversity may influence or interfere with exchange of information

During my medical school career, I have had the opportunity to serve underprivileged communities around Columbus in several different capacities. Through these experiences I have had a first hand account of how human diversity can significantly impact health care and disrupt communication of important information.

During my first two years, I was very involved with the Columbus Free Clinic (CFC) and served as a treasurer on the steering committee. At the CFC I had several experiences with patients who were from a different culture and spoke very little English. I fondly remember one experience with an elderly man who recently immigrated from China. This patient presented to the Columbus Free Clinic (CFC) with his son for an annual exam. I spent a lot of time with this patient because he did not speak much English and relied on his son to translate.  During the encounter the patient told me that he was recently seen at a Chinese American Health Fair where he was found to have an elevated A1c and was instructed to follow up with a primary care doctor. He told me how difficult it was for him to navigate the health care system to identify a clinic who could provide subsidized health care. After talking to the patient, I realized how hard it was to gain entry to the health care system if you did not have an established primary care physician who could refer you to other providers.

 

During this visit, I also noticed that I couldn’t build a rapport like I normally could with English speaking patients. I felt that I wasn’t entirely understanding the patient’s concerns and addressing them appropriately. The patient couldn’t read English so I was unable to even provide resources that the patient could read about. The literacy issues also prevented the patient from passing his driver’s test in order to get a license, which was another social factor impacting his inability to access health care. Looking back, I can’t imagine how hard it must have been for this patient to take a test in a foreign language and interact with health care providers in a foreign environment.  To fix this issue in the future, our clinic created important education materials in several different languages as evidenced below.

Artifact 2: Basic information about Diabetes in Chinese

 

At the CFC I also learned how important it was to collect a diverse set of opinions before making decisions for the entire clinic. As a steering committee our primary goal was to continue to expand our services and to serve as many patients as possible. As a result, we added acupuncture services, in house PT, and a variety of other services for patients. As a committee we felt that we were providing excellent patient care. It wasn’t until we sent out patient satisfaction surveys and talked to our undergraduate volunteers and other providers that we realized our deficiencies. These various stakeholders in the CFC commented that parking was an issue and prevented patients from coming to the clinic, and the long wait times led to patients going home late on public transportation that put them in unsafe environments. Due to this feedback we drastically reduced the number of patients we were seeing during each clinic to ensure that all patients could go home before dark, and reimbursed patients for parking as evidenced in this budget for the clinic.  This experience highlighted how important it was to collect a diverse set of opinions from many people, and how this diverse group could more accurately represent the thoughts of everyone involved with the CFC.

Figure 2: Annual budget for CFC showcasing reimbursement for parking based on constructive criticism. 

 

Understanding how diversity can impact health care outcomes and how diversity in thought can improve group dynamics were important lessons that I learned through the CFC. In the future as a resident, I plan to always be conscious of social determinants of health and address them whenever possible. I will also try to limit my medical jargon when communicating with patients and offer reading materials at an elementary level to ensure patients of all literacy levels can understand it. Another goal of mine is to always create diverse teams/groups to ensure that as many perspectives as possible are included.

Commitment to Life Long Learning in Orthopaedic Surgery

3.2: Seek out and apply best practices, measure the effect of changes and develop strategies to improve performance

When I started medical school I was excited for the opportunity to learn the basic sciences and various pathological findings that would help me treat my future patients. At the time I believed that once I graduated from medical school, I would have mastered the core medical knowledge that I needed to practice medicine, and the rest of my career would be spent honing my clinical decision making. This naïve mindset has been challenged over the course of my medical school career as I transition from a student to a health care provider.

Earlier this year, I spent several months in various orthopaedic surgical subspecialties as I prepared to submit my ERAS application. On these rotations, I learned the importance of always applying evidence based medicine and not just relying on techniques that we are most familiar with. I also witnessed the importance of staying up to date on current technology and literature.

One of the first cases that I scrubbed in for during medical school was a routine distal radius fracture that required immobilization with a volar plaster splint post-op. I was surprised to see my attending cutting the dressing along one side and re-wrapping with an ace bandage. When I asked him about this unique technique, he explained that splitting the splint better allows the dressing to accommodate soft tissue swelling post-op, which ultimately will reduce the patient’s perception of pain. There was no existing literature that determined the efficacy of this technique to reduce below dressing pressure at the time. As a result, I spent the summer between my first and second years designing an experimental model to test how splitting the cotton beneath a splint impacted below dressing pressure. This study did show a statistically significant reduction in below dressing pressure by splitting the splint and was later published in the Journal of Hand. I was the first author for this study. Later during my residency interviews, numerous hand surgeons across the country brought up this study. They noted that they had tried this technique and anecdotally noticed an improvement in patient perception of pain after splitting the splint. I was surprised to see that other hand surgeons who have been in practice for several years, were so willing to change their practice to reflect the most recent evidence based practices. From this experience, I realized the importance of staying up to date on current literature and how research can impact clinical outcomes. I was also very proud of my contribution to the field. My research helped me get inducted into the Landacre Honor Society and I was also recognized as a research scholar at the student achievement celebration dinner for the Class of 2020.

Artifact 1: Highlights various research accomplishments during medical school.

Similarly, I was involved in a complex spinal fusion that required the use of various intra-op technology. The particular case that I was involved in utilized an antero-lateral approach to the anterior spine, which I was later surprised to learn to was just the second such case in Ohio. New instrumentation (such as the O-arm illustrated below), intra-op CT guided fixation, and other advances allowed this approach to avoid vital structures (i.e aorta) during the approach. After the case, I talked to my attending about how she learns new approaches and the process before they attempt it on a patient. She explained that she follows a very thorough process where she attends an industry sponsored hands on course, practices on cadaveric specimens, and works with other surgeons who have experience with the technique prior to implanting the technique in her practice.  This was a very impactful conversation, because it highlighted that medicine is a life long learning opportunity. In my future practice, I hope to be open minded so that I can continue to incorporate new techniques and technology into my practice.

Artifact 2: O-arm

Moving forward these lessons are very important to my future career in orthopaedic surgery. Inspired by these stories, one of my goals during residency is to attend a hands on course annually to learn new advancements in fracture fixation. Next year my goal is to attend the AO basic principles of fracture management course. I also have a goal of practicing academic medicine, so I want to continue to be involved in research. As a resident, I want to continue to identify under researched areas of orthopaedics and design novel studies that answer important clinical questions. These experiences that I have illustrated in this post highlighted the importance of staying up to date with current literature and being flexible with your practice. By incorporating these lessons in my future practice, I hope to provide the best evidenced based care that I can for my patients.

Artifact 3: AO Basics Course that I hope to attend next year

Medical Knowledge: Proficiency with Procedures

2.4 Understand the indications, contraindications and potential complications of common clinical procedures and perform the basic clinical procedures expected for a new PGY-1.

Coming into medical school, I knew that I wanted to go into orthopaedic surgery. Growing up I loved watching sports and always wanted to take care of athletes. This coupled with my fascination with procedures and working with my hands made orthopaedic surgery an easy choice for me. During my first year of medical school, I was paired up with Dr. Goyal, an orthopaedic hand surgeon for my LP. During LP, I had a lot of opportunities to work on my suturing, put on splints/casts, remove sutures, and perform other basic procedures. In this process, I was able to understand the basic principle for how to consent patients, how to reassure patients during a procedure and most importantly how to perform procedures safely. During my third year, I actively sought out procedures to improve my confidence and to ensure that I had some proficiency before starting intern year. This is evidence in my third year evaluations referenced below.

 

Artifact 1: Third year evaluations highlighting proficiency with procedures.

 

My 3 away rotations earlier this year marked the culmination of everything I learned during my first three years of medical school. I worked really hard before starting my away rotations to work on splinting/casting techniques, suturing, basic reductions, bedside I&Ds, and other routine orthopedic procedures. As a result on my aways, I was treated as an intern and was given opportunities to perform procedures and triage patients independently in the ED. I remember my first such experience at the University of Iowa. It was a young IV drug user who presented with a superficial abscess on his forearm. After initially seeing the patient and staffing it with the resident, I was given the opportunity to perform a bedside I&D. As this was my first independent procedure I spent a lot of time going over my technique. In the back of my mind, I was very conscious of the patient and not wanting to do any harm. I consented and performed this procedure with the help of a resident. The evaluations below highlight my ability to perform procedures in acute orthopedic trauma patients at several institutions.

Artifact 2: Away rotation evaluations.

This experience marked one of the proudest moments of my medical school career, but it also taught me a lot of important lessons. Looking back, I remember the trust and the confidence that the patient placed in me to help him out. For the rest of my career, I want to make sure that I have the knowledge and ability to perform a procedure effectively without harming the patient. I also want to be realistic with myself and admit when I need help in the future as an intern.  Although as a resident my primary goal is to learn the skills necessary to become an orthopedic surgery, my goal is always value patient safety before performing any procedures. Due to these experiences I feel very confident to perform basic procedures and help in the OR as an intern.

 

Examples of various procedures I performed are noted below. All patients were asked for permission to take pictures.

Artifact 3: Examples of suturing, casting, and external fixation that I performed.

Patient Care: Importance of Value Based Care

1.3: Use the best available information to develop patient care plans that reflect cost-effective utilization of diagnostic tools and therapeutic interventions appropriate for each unique patient and/or patient population and that are delivered in a compassionate, safe and error-limited environment.

Over the last few months, I had the opportunity to travel all across the country to interview for an orthopaedic surgery residency position. During one such interview, I remember sitting down with the program director and being asked to draw my favorite bone on the white board. I quickly drew my best representation of a femur, only for the PD to sarcastically comment about how that may be the most dysplastic femur he has ever seen. We then spent the next few minutes talking about what surgery I would do for each type of hip fracture that he drew. His last question to me was about how I would treat a sub-capital femoral fracture in a hospice patient. Confidently, I answered that I would do a hemi-arthroplasty given that it’s a faster operation with less morbidity, and in the past we used this implant in patients who were expected to live for less than a year. The PD paused and asked what else I could try. I responded maybe a short nail vs cannulated screws. He smirked and questioned if we really needed to operate on this patient. Would a surgery actually improve this patient’s quality of life? I vividly remember this encounter because it emphasized the importance of value based care. Weeks after this interview I continued to reflect back on my medical school experience to identify other lessons I learned about value based care and personalized medicine.

Artifact 1: Indications for a hip hemi-arthroplasty

 

As a medical student during my pre-clinical years, I spent a majority of my time learning the various differentials for common complaints and almost memorizing diagnostic algorithms. When I saw a patient in LP, during an OSCE, or at the Columbus Free Clinic (CFC) I would refer back to my algorithms to ask almost a series of checklist like questions and order a pre-meditated battery of tests. One of my first reflective posts captured this attitude of viewing each encounter as a series of questions that had to be asked to do well (screenshot below).

Artifact 2: Part 1 portfolio post excerpt

 

This very algorithmic approach to medicine was called into question during one volunteer shift at the CFC. I had a routine patient coming in with Diabetes. During the visit I counseled the patient on the importance of eating well, exercising, checking sugar levels regularly, taking meds and consistently seeing us. I also ordered basic lab work (Chem to check for renal function, A1c, etc.), referral to ophthalmology for an eye exam, and did a diabetic foot exam. The staff physician after listening to my plan applauded my thoroughness but asked if I thought this was plausible for this patient. I was confused and didn’t understand what the physician was alluding to, and asked him for clarification. He explained that in this underserved population, the patients usually don’t have the resources to purchase a glucometer, medications and often don’t have a consistent method of transportation to attend all of these appointments. As a result, we must do as much as possible at today’s visit and provide the patient with all of the required education and medications. Experiences like this motivated my community health education (CHE) project at the CFC, which was a comprehensive longitudinal diabetes program. Each newly diagnosed diabetes patient received glucometers with strips, formal standardized education about the disease, dietician follow up at the CFC, access to CFC sponsored fresh produce, long term supply of medications and other services to help each patient. The artifact below is our group presenting this poster. From these experiences, I learned that each plan must be uniquely tailored to each patient and socioeconomic constraints of each patient must be taken into account to prevent the inefficient use of valuable health care resources.

Artifact 3: CFC steering committee presenting CHE poster.

 

Overall, my experiences at the CFC and during my interviews this year have drastically reshaped my perspective on how medicine should be practiced. I am hoping to transition from the algorithmic style of medicine I was accustomed to early on in my career, to a more valued based individualized style. In my past few rotations, I have had extensive conversations about the appropriateness of antibiotics in chronic wounds, use of d-dimer in the ED, and whether an ammonia level is actually clinically warranted for a diagnosis of hepatic encephalopathy. These conversations have further shaped my practice. The final artifact below from recent evaluations showcase my newfound interest in value/evidence based care.

 

Artifact 4: Evaluation comments from last rotation

 

As a resident, I want to continue to develop these value based care principles. One of my goals for the future, is to consistently question why we are doing something for a patient and probe my attending surgeons for why we do things in a certain way. These conversations will better influence my future practice styles. After my interview day experience outlined previously, I hope to not use textbook indications for surgery to force surgery on my patients. Instead, I want to have an open conversation with my patients about their preferences and take into account their unique characteristics.