Posts

Effective listening and communication skills

by

Competency: Patient care

Throughout the last couple years, I have realized how important effective listening skills are in patient care. This learning process started immediately during my first clinical rotation. I did L&D and Gyn and Mount Carmel St. Anne’s hospital where I quickly realized how important both effective listening and communication are when taking care of patients. I distinctly remember the many cases of vaginal bleeding my resident and I saw when consulted to the ED. Many times, these patients were in the midst of a spontaneous loss. Managing patients who were going through this was a rewarding experience. My resident let me interview and counsel a patient who was most likely having a spontaneous loss. She advised me to always ask the patient how they were feeling about the pregnancy before making any assumptions about how the patient felt about the spontaneous loss. This fact helped me relate to the patient on a major level and helped me with my patient care. When I talked to my patient, I introduced myself, asked her a couple questions, and then asked her how she felt about the pregnancy. She replied to me that she was not ready for the pregnancy and that everything happened for a reason. The second patient I saw that night was going through a similar situation. When I asked her how she felt about the pregnancy, she immediately started sobbing. These two experiences showed me patients on two different ends of the spectrum. In these situations, it was so important to listen and understand the values of the patient in order to best communicate. This skill helped me throughout the rest of third and fourth year and was one of the important reasons I choose psychiatry.

Another example of when I valued the importance of effective listening was on my third year medicine rotation. A patient of ours decided during the course of her hospitalization that she was going to remove herself from a 25 year relationship involving physical and emotional abuse. I remember being able to take time and sit down with my patient to listen to her stressors and this helped me build a strong rapport with the patient. I was able to give her confidence in her decision to eventually leave her husband. I have always felt like I have been a good listener, however, my major goal for the rest of third and fourth year were to be able to effectively listen in an efficient way. Yes, it is very important to understand the patient perspective. However, as I get busier in residency I want to be able to prioritize what is most important to the patient, what is most important as a clinician, and try to merge interests.

Update:

In my fourth year, I took a palliative care elective, in which all the skills I had learned about communication during my third year of medical school was put to test. I really learned how so many doctors fall into the trap of advising before understanding where the patient is coming from. We would receive many consults to assess goals of care for patients which would many times be completely misunderstand by primary teams. This rotation really taught me how important medical decisions can drastically change based on how much you listen, understand, and question the patient. Throughout this experience, I was able to practice my listening skills as well as lead a goals of treatment conversation (albeit with extreme guidance of my attending). I was able to understand what was important to the patient (and family), what was important to us as providers, and come together in the end. It was a great way to practice some of the goals I had made for myself earlier in the year.

In order to further practice this important skill, I plan on continuing to ask open-ended questions to patients during the start of my residency. As I am going into psychiatry, I think this is an extremely important skill. I also want to practice having an agenda in my head of what I want to talk about during my time with a patient so I am able to efficiently communicate as well in order to improve patient care.

 

Below is an artifact from my palliative care rotation.

Primary care transgender clinic QI project

by

Competency: Practice-based and lifelong learning

Starting last year, we started a quality improvement project through AHSS which focused on improving patient education when initiating hormone replacement therapy (HRT) at Ohio State’s Transgender Primary Care Clinic (TPCC). Our group, with guidance from the providers at the clinic found that patients interested in HRT at TPCC left preliminary visits with many questions and felt inadequately educated about risk/benefits and expectations of HRT. This resulted in increased encounters, in the form of MyChart messages. The increased volume of MyChart messages interfered with clinic efficiency and may possibly have reflected poor patient satisfaction with therapy. We sought to decrease ratio of MyChart encounters related to risk/benefits and expectations of HRT by a significant percentile by the end of February 2020.

In order to determine why patients left inadequately educated, we first listened to the voice of the customer and found that patients who visit the clinic interested in HRT and TPCC leave preliminary visits with many questions regarding risk/benefits and expectations of HRT. With our preliminary data from this voice of customer, we saw that indeed patients had many questions once they left their preliminary visits at the clinic. Patients found provided homegoing resources insufficient. After doing a 5-why analysis, we again determined that condensing the homegoing resources would be a good place to intervene in order to improve patient education. We decided to work diligently to put together our implementation: a packet of information intended for patients beginning HRT. This process proved to be the most difficult thus far, as the seven of us were in the midst of interview season. However, we were able to divide-and-conquer the load and develop a plain-text version of what will eventually be a brand-nw information packet, professionally designed with the help of a marketing firm that we have been put in contact with thanks to the faculty at TPCC. The information packet was completed by the end of November and we began distribution in December. Our entire intervention, including our initial surveys, will have been in place for well over 12 weeks by our initial end-date of February 2020. In order to better gauge education/understanding of HRT risks/benefits and expectations we developed a survey which patients filled out both in October (pre-intervention) and February (post-intervention).

This project has shown me the importance of consistently questioning why things are structured the ways they are. This is the only way we will be able to make systematic improvements in order to improve patient care. It has also taught me that the role of both the physician and student is not just to provide care – but to understand the barriers that patients face in receiving that care. It is important to put yourself in the shoes of the patient to understand how we can better the system in order to give more efficient care. Before this project, I never considered myself a strong leader. I never thought I would be able to point out errors in a system and actually make a difference. Although, I have still much to learn in terms of being a strong leader, I have become more comfortable questioning errors in the healthcare system and trying to come up with alternative solutions. Nothing is perfect, however it is our duty to try to improve the system in order to better serve our patient population. My goal in the remainder of medical school is to continue read more about the characteristics of being a good leader and seek out mentorship in this area. I plan on taking more leadership roles throughout residency and acquiring feedback from medical students, other residents, and attendings.

Artifact: Cause and Effect Fishbone diagram

 

Life and death situations

by

Competency: Professionalism

Beep Beep Beep…the all too familiar sound of my pager seemed to go off for the 15th time that night. This time it was 3:30 AM and I rushed to get down to the trauma bay. Although, it seemed as though I was moving at light-speed, there were already 20 people in the patient’s room. When I put on my gown, mask, and gloves I was told to start giving CPR. I had no idea what had happened but I knew it was my turn to help out. The code ran so smoothly. The ER physician was running the code, distributing tasks to those in the room in an extremely organized manner. CPR, pulse check, epinephrine…over and over again. Sadly, after 30 minutes the attending physician called the time of death.

This situation was an alarming but great learning experience. It made me realize how important it is to remain calm and organized during such a chaotic event. This experience also exemplified the importance of professionalism in a situation in which many may have lacked that quality. Everyone was able to focus their best efforts in taking care of the patient while still remembering they were to remain calm and collected in a hospital setting.

After the code ended, the team gathered and started talking about what went right and what may have gone wrong in that code situation. The team was able to talk to each other, taking their emotions out of the situation, and figure out how they may remedy the situation should it arise again. This air of professionalism in a life or death situation was remarkable to me. I was devastated after the code and it will take a while for me to be able to remain calm after a patient dies in order to focus on how to move on and learn from the experience.

I generally take pride in my professionalism. My evaluations so far have stated that I have been easy to work with and care about my patients while still remaining professional. However, circumstances like these really test me. I am excited to learn and grow during moments like these in my future. During the rest of my medical school career, I want to be able to develop coping strategies in order to maintain my emotional state during high-intensity situations.

Update:

During the rest of my third and fourth year, situations like this never became any easier, however I was able to develop coping strategies in order to overcome emotional obstacles that are inherently there in medicine. During my psychiatry rotations, I was emotionally tested in numerous different ways when managing crisis situations and learned how to perform in a professional manner while at the same time learning how to cope with my own emotions during these situations. Some of these coping strategies included breathing techniques, journaling about my feelings at home, and talking to loved ones. Maintaining professionalism in the field of psychiatry is extremely important when dealing with crisis situations. The provider must remain calm in order to provide the best care and although I have much to learn I have come a long way in the last few years. I hope to continue to find outlets in order to be able to maintain a professional nature in the clinical environment. This includes working out more, spending time with family and friends, and doing things I enjoy outside of work.

 

Artifact: Expert from a letter of recommendation during my General med service demonstrating professionalism

“A patient of ours decided during the course of her hospitalization that she was going to
remove herself from a 25 year relationship involving physical and emotional abuse, and Kavin’s
compassion and daily therapeutic listening sessions helped to relieve her stress and give her
confidence in her decision. Kavin is an ideal professional and worked well with all members of the
health care team. He actively sought constructive criticism and incorporated that feedback into his
performance. He took responsibility for his own learning and presented a well-researched lecture on
venous thromboembolism during the rotation.”

Working with a multi-disciplinary team

by

Competency: Systems-based practice

Throughout my last two years of medical school, I have realized the importance of teamwork which has led to my better understanding of systems-based practice, specifically working inter-professional teams to enhance patient safety and improve patient care quality. I first realized this during my third year pulmonary consult rotation where I worked primarily in the ICU. During this service, we spent our mornings rounding in the ICU. I did not realize how many different groups of people took care of each individual patient. These included the ICU hospitalist, pulmonology team, palliative care physician, nutritionist, nurse, social worker, chaplain, respiratory technicians, and pharmacists. This process was quite efficient and helped reduce errors in patient care. Throughout my three weeks, I really looked up to my fellow who was able to lead such a diverse group of people. He would start by giving a brief synopsis of each patient and then go to each respective team member for their report. He took everyone’s opinions into consideration before making a final plan because he was truly concerned about the well-being of each patient. I look forward to one day being able to lead a multi-disciplinary team to help provide the best patient care.

During my fourth year, I spent two weeks in the YCSU at Nationwide Children’s Hospital. This unit was designed in order to help children/adolescents through crisis situations that led them to have suicidal thoughts or in some cases suicidal attempts. During this rotation, I again realized the importance of systems-based practice in medical care. The unit consisted of psychiatrists, pediatricians, therapeutic recreation specialists, social workers, counselors, nurses and technicians all working together to help these children through tough times. There was one case which stood out to me that demonstrated the importance of interdisciplinary care. We had a young girl with borderline traits presenting with a mirage of neurologic symptoms and suicidal intent. In order to take care of her, we had to come up with a strategy to cater to her new condition. First, the pediatricians had to rule out any medical condition.  Next, the rest of the team had to play their role to help identify the underlying issues that the girl was facing. However, this strategy would only work if every member of the team worked together. For example, the therapeutic recreation specialists would not allow her to play cards because it would have worsened her vision problems. The nurses would not let her out of the bed without them because of her balance issues. Together, we worked as a team to combat her physical complaints until she finally confided in us that she was acting out in order to get attention from her parents. We were then able to delve more into their relationship and help her out in the long run. Working with people in different specialties in order to help take care of your patient is crucial. It is important to realize that everyone has a different skill set and no one can master it all. After my two weeks on this unit, I was able to work with many of the different therapists and received an evaluation that stated I was successful with my collaborations. Throughout the rest of my fourth year, I want to familiarize myself more with the therapeutic aspect of psychiatric care in order to be able to best utilize this therapy in my future career as a psychiatrist and be able to collaborate successfully.

Update:

I set a goal to familiarize myself more with the therapeutic aspect of psychiatric care and feel like I have done so successfully in the past few months. During the interview season, I have met many different leaders in the field of psychiatry who have pointed me to different literature and articles pertinent to the area I am interested in. I am excited to continue to learn more about the psychological aspect of psychiatric care in order to improve my therapy skills as a future resident. This will be accomplished by working with counselors and psychologists more often through interdisciplinary meetings during my residency.

Medic Ride Along

by

Competency: Interpersonal Communication

During my Emergency medicine rotation, I was given the opportunity to spend a day with S. McCrary and R Heitkamp on a ride along medic run. I was able to observe the initial stabilization measures taken before taking patients to the hospital. I also importantly learned the value in interpersonal communication skills, specifically how to collaborate effectively and efficiently with other members in the healthcare team in the eyes of EMTs and medics on the field.

The day started off with a transition of care from the previous team to our team. I then toured the station and saw where the medics and EMTs stayed, where they ate, and where they worked. Around 9 AM, we received our first call which was an “ill” call. The man was picked up from his truck as he was homeless and was complaining of a headache. He was stable and taken to Riverside Methodist hospital. We then had a string of MVCs, all thankfully in stable condition. The first MVC occurred after a high speed police chase ended up in a collision. The woman complained of some flank pain and had minor abrasions but was doing well otherwise. We then had a pedestrian collision. The woman complained of some left breast wall tenderness so we got an EKG to rule out anything cardiac and took her to Grant hospital which specializes in trauma. We finally went on a run for a psychiatric patient. The patient was at a local Baptist church with multiple drug paraphernalia complaining that he was possessed and trying to get the demons out of him. The patient was initially aggressive and our medics had to call their supervisor in order to use ketamine. Fortunately, we were able to calm the patient down and ketamine was avoided.

What impacted me the most was the ability of the medics to efficiently communicate with the nurses and physicians at the incoming hospitals. Thankfully, most of our patients were in stable conditions, however, it made me realize how important it is in life-threatening situations to quickly, yet thoroughly communicate with others in order to provide the best care for the patient. I have sometimes struggled with parsing out what information about a patient is important and what is not. During my fourth year, I feel like I have drastically been able to improve in this aspect and have been able to practice this in my Emergency Medicine rotation. Although I have improved, I still have a way to go before perfecting this skill. Although, I am going in to psychiatry, there are many emergency situations in which information needs to be passed quickly. Throughout the rest of my EM rotation, I want to be able to practice condensing my presentations within one minute. I will have my attending give me feedback at the end of my rotation to make sure I am doing this efficiently. I hope by the end of my rotation, I will further improve this skill.

Update: By the end of my EM shift I felt like my presentations became more efficient. I was able to develop a differential in a quick amount of time and successfully include don’t want to miss diagnosis, first tier diagnosis, and second tier diagnoses. This was reflected in my evaluations (see below).

My updated goal is to learn to develop and build on my confidence and poise when expressing myself. Sometimes I struggle with talking to others with authority because I feel like I have no expertise in the subject. I will continue to work on my confidence when talking to other team members throughout residency by making sure my knowledge on the subject is clear before presenting to others. I will measure this through acquiring feedback from the attendings I work with throughout my intern year.

The role of inflammation in schizophrenia

by

Competency: Medical Knowledge and skills

I am currently on my Psychiatry sub-internship at The Ohio State University. Our service sees many patients with treatment resistant schizophrenia. Many of the patients we take care of are being titrated on clozapine during their inpatient stay. We have one young man who was a successful college student studying graphic decision who had his first psychotic episode at the age of 17.  Since then he has been on many different anti-psychotics including clozapine. Unfortunately, he developed myocarditis on clozapine and had to be taken off of it in the past.  He returned to our service after 2 years of decompensation and was extremely thought disordered.  Throughout his stay, we have been working on re-challenging him on clozapine, however he does not have a guardian, so we are working on different ways to help this young man. About 2 weeks into his admission, my attending and I had seen that he had an elevated CRP. We both performed a literature search and found that patients with schizophrenia and elevated CRPs may benefit from anti-inflammatory agents.  We eventually decided to start him on an anti-inflammatory agent, Celebrex. I was surprised and excited to see that there was a potential alternative treatment option for our patient; however, I was also interested in this due to my previous research in immunology. My PhD work focused on studying the role of monocytes/macrophages in antibody therapy against cancer. Here, I have included a paper that I worked on during my PhD research which describes how to enhance macrophage effector function in antibody-mediated therapy. Before pursuing psychiatry, I was worried how my research in immunology would fit in the field. However, after this rotation I realized how wide open the field of neuro-immunology is. Throughout the next few weeks, I researched many different articles and reviews on the connection between inflammation and different mental health issues, specifically schizophrenia.  I was able to see that microglia (macrophages in the brain) played an important role in certain genetic variants of schizophrenia. I also was able to see that there are new clinical trials using different monoclonal antibodies against pro-inflammatory cytokines in the treatment of schizophrenia. Although there is still much room for growth in terms of my patient care competency, it was nice to be able to use evidence-based medicine in order to help deliver personalized care to our patient. This experience showed me the importance of using more than just uptodate in situations where you feel like there is nothing more you can do for the patient in order to deliver superior care. My goal is to read more literature when treating patients in order to deliver personalized care. I will track this goal by making sure I keep a document logging papers which I find helpful in relation to certain patients. I plan on doing this throughout the rest of my career. This experience reassured me that I would eventually be able to marry my clinical passion with my research interests to help patients with mental health illness.

J. Biol. Chem.-2016-Fatehchand-3895-904