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Using QI Projects to Contribute to Medicine

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

CEO 3.3 Demonstrate an understanding of the role of the student and the physician in the improvement of the healthcare delivery system.

 

As I have progressed through medical school, I have recognized the importance of evidence- based medicine. Throughout all of M1 and M2, the preclinical training was based upon a foundation of research. While I was cognizant of this prior to entering my clinical years, I was having difficulty understanding how to incorporate evidence based medicine into everyday practice. I found it overwhelming to try to balance the knowledge I already had with acquiring new knowledge.   I did not realize that utilizing resources while on the wards was not only acceptable, but encouraged.

 

I received feedback from my third year general medicine rotation that I needed to expand upon my medical knowledge. While I went home and focused on methods such as Anki and clinical questions, my medical knowledge increased yet I still needed to improve upon the medical management plans. I received feedback from an evaluation to go home and spend 15 minutes reading UpToDate for the management of a condition I came across with my patient that day. When I started to implement UpToDate and the Hospitalist Handbook in the clinical setting, my plans began to improve as did my understanding of medical management. For example, using these resources, I could quickly determine what the maximal dosage was for a medication for the clinical indication.  My improved ability to develop medical plans for patients resulted in me being able to provide better care to patients.

Mini-I Feedback

During my fourth year, I started to understand the importance of critically analyzing the healthcare delivery system to improve patient care and outcomes. As part of Part 3 curriculum, I had to complete a QI project. This provided a perfect opportunity to improve upon patient care by recognizing deficits of the system. My group’s project was focused on decreasing 60 -day readmission rates to the Ross Heart Hospital for patients with acute exacerbations of heart failure.   After gathering data from stakeholders, the group decided health literacy and complexity of medication regimen were root causes of the problem.  By critically analyzing the root causes of the readmission rates, our group was able to determine what was impeding better care.

 

The intervention was aimed at addressing the root causes by using a standardized document with the list of medications including their class of medication, and the importance of taking the medications regularly. On the day of discharge, the nurses reviewed the document with the patients.  Bedside nurses implemented the teach-back method to ensure the patients understood their medication regimen.

 

With the implementation of the intervention, the heart failure readmission rates decreased from 38 to 19. The QI project helped me realize the role of the physician and student in the healthcare system was not only follow guidelines set forth by the research of others, but to be able to critically analyze what is occurring in the clinical environment to improve upon any processes.

After having completed a QI project in medical school, I realize I am in a unique position to expand upon these skills in residency.  As I move forward, I would like to complete more QI projects as they can ultimately improve upon patient lives while allowing me to make contributions to the field of medicine.

 

Learning From Past Experiences

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CEO 2.1: Demonstrate a broad working knowledge of the fundamental science, principles, and processes basic to the practice of medicine and apply this knowledge in a judicious and consistent manner to prevent common health problems and achieve effective and safe patient care.

 

Imposter syndrome is something I have struggled with throughout medical school. Being I an environment where everyone is intelligent, can sometimes make me feel inadequate. My imposter syndrome was made worse when I had to take an LOA to study for Step 1. Throughout my first two years, I passed my tests but never excelled in my studies. I thought I knew enough, however, I came to realize my medical knowledge was not adequate enough to be able to pass step 1.

 

After a lot of introspection, I realized I had to change my studying habits. Through this I was able to discover, I was in the right place. I needed a different strategy of studying.  I was able to perform well on Step 1 ( and eventually Step 2) and continue with M3.   At this time I felt nervous but ready to take on the responsibility of participating on clinical wards.

As I have been on the wards, I have made an effort to study dutifully so that I could participate on rounds.   My medical knowledge increased as I progressed through my clinical rotations.  My evaluations in my fourth year also began to reflect the increase in my confidence. I began to grow more comfortable in my role and my evaluations began to reflect this newfound confidence.

AMRCC Feedback

Something I have noticed more and more in medicine is that physicians and medical students often think we do a better job of teaching patients than we do. I think sometimes it is hard to remember a time where you did not have  that knowledge.

 

Because of the difficulties I had with Step, I make an extra effort to explain concepts to patients in terms they may understand. From explaining why a certain physical exam task is performed to answering questions about why a patient is taking a medication, I try to answer my patients’ questions thoroughly.

 

During my hospital medicine rotation, there was a patient who had been admitted for newly diagnosed decompensated cirrhosis. The etiology was more than likely alcohol. Prior to arriving at the hospital, she received a workup to determine the etiology of the cirrhosis. During the few days she was on the hospitalist service, I was able to sit down with her and address the questions she had regarding her diagnosis.  I was able to explain to her the negative workup she had as well as explain why each lab or imagining study was obtained.   It should be mentioned that both attending physicians had taken time to answer the patient’s questions as well.   After discussing the information with the patient, she was appreciative of the time I took to spend with her.

 

This experience taught me how important it is to have a strong foundation of medical knowledge. My knowledge allowed me to explain the information well to my patient. Sitting there talking to the patient made me feel confident in my clinical abilities. I no longer focused on my past shortcomings and knowledge deficits, but instead used that to my advantage to understand the difficulty patients may have with grasping medical information. My past knowledge deficits have made me a more empathetic provider.   As I began to find my strengths in the clinical environment, I became more confident in my abilities as a medical student.

 

 

As I look towards intern year, I would like to expand upon the medical knowledge I have acquired. I would like to build upon the knowledge I have gained and continue to use my empathetic listening skills to listen to patients and provide them with the knowledge to empower them to make decisions regarding their healthcare.

Using Language to Bridge Communication

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CEO 5.2 Appropriately use system resources and assist patients in accessing healthcare that is safe, effective, patient centered, timely, efficient, and equitable.

 

Prior to medical school, I completed a program evaluation for a diabetes education program as my capstone project for my MPH degree. Barriers in the form of language and resources existed. Many patients were non-English speaking and were able to receive services with the help of an interpreter. Many patients did not have higher education. I watched the complexity with which diabetes was explained. The resources provided in the form of translator services, and diabetes educators helped patients to be able to gain access to healthcare. I was also able to see how providing a patient with the proper resources could help them manage their diabetes. It was there that I learned the importance of access to health services and my desire to advocate for patients was awakened.

 

I recognized I wanted to increase healthcare access to patients population while in medical school.   In an effort to accomplish this, I spent time volunteering at La Clinica Latina during M1 and M2 years.   It was here where I was able to improve upon my medical Spanish. By serving as an interpreter, I was able to help provide medical care for patients that otherwise may have had trouble accessing care.

My introduction to third year was the UPWP ring. This ring provided several opportunities to Spanish speaking interpreting skills.   When I was on my PM&R service, I was able to interpret for a patient. This was the first time on the wards, I was able to see the ease with which rapport could be built between provider and patient when a common foreign language is spoken.   When on a pediatric outpatient rotation, I was assured by a patient’s mother how nice it was to be able to speak to a provider in their native tongue so that nothing would be lost in translation. As the interpreter for the patient, I was able to bridge the communication barrier that existed between the patient and the team.

 

While on my ED rotation, I was able to once again implement my medical Spanish. There was a Spanish- speaking patient with a suspected small bowel obstruction that arrived from an outside hospital around 5 am.   At this point I was tired as it was nearing the end of my overnight shift. Walking into the room, the nurse informed me the patient was Spanish speaking. I had no time to think about speaking Spanish, it just came out naturally. I was able to converse with ease with this patient.   During this encounter I was able to notify nurse that the patient was asking for pain medication. I was also able to help get the patient a blanket. While an interpreter could have been used if I did not speak the same language as the patient, it would have taken twice as long to determine what the patient needed. By speaking a common language, I was able to advocate for the patient quicker.

 

I learned from this that having a diverse healthcare team is both necessary and important to serve a diverse patient population. If I had not known Spanish, I would have had to call an interpreter, resulting in a delay of care for the patient. There have been documented cases of black and Latino patients receiving less care for their pain management. By having the ability to speak Spanish, I was able to bring attention to the pain experienced by the patient. Being able to advocate for patients in a timely manner allows me to provide the best care that I can.

As a resident, I hope to continue using my Spanish speaking skills to advocate for patients.   Utilizing resources provided by the hospital, such as nursing staff, social work, case managers, and consult services will allow me to provide optimal care for my patients.

Citation:

Lee P, Saux ML, Siegel R, et al.  Racial and ethnic disparities in the management of acute pain in US emergency departments: Meta-analysis and systematic review.  AM J Emerg Med. 2019 Sep;37 (9):1770-1777. doi:10.1016/j.ajem.2019.06.014.

Learning Through Presentations

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CEO 4.6 Effectively prepare and deliver educational materials to individuals and groups

One of my greatest areas of growth in medical school has been interpersonal communication. I have always been a timid individual when it comes to public speaking. Part of my dislike of presentations is the overwhelming anxiety they bring me. In order to prepare for presentations, I have a habit of writing down everything I am going to say when presenting and trying to memorize it by practicing several times before giving the presentation.   I believe this is partially due to my fear of being wrong.

 

Medical school has forced me to confront my fear of public speaking. When I had to complete case presentations in LG, I would always choose to present the history of present illness or the behavioral sciences portion. I would not volunteer to present the basic science section as I did not have the confidence necessary to believe I could present the basic sciences section well.

 

Throughout M3 and M4, I grew accustomed to presenting patients on rounds, participating in small informal presentations aimed at educating my peers, and case presentations. The first time I had to present a patient was on my pediatric cardiology rotation, where I had to present to a large team of interdisciplinary providers. I remember the anxiety I felt at delivering this important clinical information. Afterwards I remember the relief I felt. I also remember feeling proud of myself for being able to present. At the conclusion of the rotation, I remember getting positive feedback regarding the organization of my presentations. This positive feedback helped me to feel confident in my presentation skills. I slowly started to become more comfortable with the act of public speaking.

 

One presentation that stood out to me was a presentation where I was required to talk about appendicitis during my surgical rotation. I practiced several times so that I could deliver the presentation confidently. From this formal presentation, I understood the important role research played into delivering a presentation. I spent time researching appendicitis so that I could effectively deliver the pathophysiology during the presentation. While I knew basic management skills of appendicitis, researching information is always important to ensure that the most current information is used. During my preparation, I was able to learn about the Alvarado score used when there is clinical suspicion of appendicitis. I also learned how the use of Powerpoint can help to organize information in a manner that can be disseminate easily.

I am currently in a radiology elective. One of the requirements of the course is to develop a presentation of a critically appraised topic. My topic is determining when to use CT scans in a patient with altered mental status.  While I have not yet delivered my presentation, I will use the skills I have gained through medical school to effectively gather the information, as well as confidently teach my peers on a topic that is clinically relevant.

Shared Decision-Making in Patient Care

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CEO 1.1 Patient Care: Approach the care of a patient as a cooperative endeavor , integrating patients’ concerns, and ensuring their health needs are addressed.

1.3 Use the best available information to develop patient care plans that are cost effective and 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.

 

During M2 year in a LG session, I was introduced to cost effective care.   In the group activity, we were presented with a patient with a suspected pulmonary embolism. The assignment was to decide which diagnostic tests were appropriate. A list of interventions was provided, along with their associated costs. As a group, we decided to do quite an extensive and expensive workup for our patient. Our preceptor advised us to carefully choose interventions using the principles of specificity and sensitivity and evidence based medicine to guide our decisions.

 

During my M3 year, I was able to see more examples of cost effective care such as: not ordering every set of labs everyday if it was not clinically indicated; and ordering albumin with an end date for a specified amount of time so that the provider could assess whether the expensive intervention was necessary to continue.

 

During my hospitalist medicine elective, I was able to help address patient concerns.  There was a patient with a history of recurrent urinary tract infections and a suprapubic catheter who had been admitted with sepsis secondary to a urinary tract infection.  After initiating broad-spectrum antibiotics, the patient was improving clinically as evidenced by the absence of fevers and decreased white blood cell count. Once the urinalysis results returned with the susceptibilities, the antibiotics were changed to target the pathogens. The plan that day was to discharge the patient to the assisted living facility where he lived.

 

The night after the antibiotic was changed, the patient had an episode of emesis and shortness of breath overnight. The following morning, I sat with the patient to ask him about this episode. I took the time to listen to him when he expressed how scared he was following this episode. He suspected his new antibiotic caused the reaction. Given the patient had a history of adverse effects to medications, my attending and I decided to change the plan and keep the admitted patient another day. Fortunately, after keeping the patient there for one more day, he was not observed to have any other adverse reactions to the medications.

 

From this experience I learned the importance of allowing a patient to help determine the medical plan.  The technique I implemented during the shared decision- making process was the SHARE approach.  While the patient was no longer septic, he knew he did not yet feel comfortable going home. I have been taught that the patient is in charge of their health. If this is truly to be believed, it is important to allow the patient to be a part of the decision- making process that directly involves their health. By presenting the patient with the option of either going home or delaying discharge for a day, we encouraged the patient to be an active participant in his health.

SHARE Approach to Decision Making

When the patient was ready to be discharged, I was reconciling his medications with my attending. There was a new medication he had been prescribed during his stay to help with bladder spams and his leaking urinary catheter. Before deciding if the medication should have been continued at discharge, I looked up how many times the medication was used during the hospital stay to decide if it was appropriate to prescribe the patient the medication on discharge. I could see the patient did not use the medication during his hospital stay. I also looked up the price of the medication using GoodRx. After seeing the patient had not used the medication during the hospital stay and the high cost of the medication, I reasoned it was not necessary to get the prescription filled at the pharmacy.

https://www.goodrx.com/go/homepage-lander-sem-6?c=homepage-lander-sem-6&gclid=CjwKCAiA1eKBBhBZEiwAX3gql5iOqzcQUe4ZTmT3dMaDpXWSEO6eRWmS7ITsuAQhWv7QMFw1021CrRoCrzgQAvD_BwE

GoodRx Website

This experience allowed me to utilize cost effective measures when making medical decisions. It is important to think about each medication that is prescribed to a patient upon discharge. A medication should never be continued simply because it was prescribed during the inpatient stay.  Unnecessary medication costs inflict a financial burden to patients that should not be taken lightly.

 

As an intern, I want to be able to include the patient in the decision -making process. It is my job to present them with the options so that they can make the most informed decision.   I will also continue to evaluate if a medication needs to continue to be used or if it can be discontinued due to clinical improvement or not needing the medication.

 

Citations

The SHARE Approach: A Model for Shared Decisionmaking – Fact Sheet. Content last reviewed September 2020. Agency for Healthcare Research and Quality, Rockville, MD.
https://www.ahrq.gov/health-literacy/professional-training/shared-decision/tools/factsheet.html

Practicing Professionalism Through Compassion

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CEO 6: Professionalism: Above all else a graduate of The Ohio State University College of Medicine shall exemplify the ethics, values and behaviors of the medical profession. As such, the graduate must consistently demonstrate compassion, respect, honesty, integrity, accountability, altruism, prudence, social justice, and commitment to excellent in all professional and personal responsibilities.

 

Professionalism is important to me. Prior to medical school, I worked in my first patient care experience as a nursing assistant. Compassion and empathy in the form of listening to patients tell stories about their lives or helping them to preserve their dignity by helping them change when they became incontinent helped to build trust.  This trust enabled me to provide better care for my patients. It was with this experience, I learned the importance of expressing compassion towards patients.

 

During my time as a medical student, I have tried to carry through the compassion I learned to express as a nursing assistant. During M1 and M2, I volunteered at La Clinica Latina, a free clinic primarily serving Spanish -speaking patients. One of the nights I was volunteering, there was a patient that presented with depression.   In order to be able to take an accurate and complete history, I had to help build the rapport with the patient. The patient appeared to be sad and tearful. In order to help the patient feel more comfortable, I made sure to respect the patient by making eye contact and carefully listening to what the patient was saying. Subsequently they were able to trust me with the sensitive information about their drug use and suicidal ideation.  I did not act with judgment in this situation, instead I used this information to help the attending develop a plan of care.

La Clinica Latina Website

While on my general medicine mini-internship, I was prerounding on one of my patients.   After we finished talking, she stated she had to use the restroom. I remember wanting to help but being told by a resident that I should page the nurse to help. My yearning for wanting to express compassion through in a manner in which I was accustomed prior to medical school was at odds with my clinical responsibilities as a medical student. I pressed the call light to help the patient and continued rounding on my remaining patients. At this juncture of my training, I was unsure how to incorporate the compassion I wanted to express into my clinical responsibilities.  Being recognized for my professionalism in my evaluations on this service was reassuring, however, I wanted my definition of professionalism to include compassion.

Professionalism

 

 

 

 

Evaluation from General Medicine Mini-i

I was beginning to think compassion might not be something I could easily express as a medical student.   To my surprise, I was reintroduced to compassion with patients while I was on my ED rotation at OSU East Hospital. and being reminded of the kindness that is so necessary for patient interactions. The patient came in with a suspected dental abscess. The attending and I went to see the patient together. After discussing the plan of care, the attending asked the patient if she wanted water. After leaving the room, the attending asked me to get the patient a glass of water. I was taken aback by this request as I had come to think this was generally a nursing or nursing assistant responsibility.  I obtained the water for the patient and brought it back to her. She was appreciative of this compassionate gesture.

 

This experience taught me the importance of a small gesture in helping patient care.  While being able to carry out the responsibilities of a physician is important such as forming a plan of care, it is important to remember the way in which that information is delivered is just as important.   The duty to demonstrate compassion is vital in providing comprehensive care and building rapport with the patient.  I also learned that while each member may have a role that they may traditionally fill on the team, it is not above any member on the team to demonstrate compassion.  My definition of professionalism as a soon to be intern, means being able to carry out the responsibilities expected of a physician in a respectable and compassionate manner.

 

As an intern, I hope to carry forward my expanded definition of professionalism to make patients more comfortable.  Particularly during these times where patients do not have as much access to their families while in the hospital, it is important to demonstrate kindness and compassion to patients. Despite being busy as an intern, I will strive to put forth my best effort to provide the best patient care possible.   I will remember the lessons I learned as a medical student to ensure my patients are treated with compassion by providing small gestures of kindness during our interactions.