Clinical Encounter

Additional Info

• Audio File:uab/ua167.mp3
• Doctors:Mullins, Haddon;Willig, James
• Featured Speaker:Haddon Mullins, MD | James Willig, MD, MSPH
• CME Series:Quality and Outcomes
• Post Test URL:https://cmecourses.som.uab.edu/mod/quiz/view.php?id=4360
• Guest Bio:Haddon Mullins, MD is a General Surgery Resident. 
  
  James H. Willig, MD, MSPH, is the Associate Dean of Clinical Education in the School of Medicine. He attended Medical School at the Instituto Tecnologico de Santo Domingo (INTEC) and completed his residency at the University of Virginia Roanoke-Salem. At UAB, Willig has earned an M.S. in Public Health and completed an Infectious Diseases Fellowship. 
  
  
  Learn more about James Willig, MD, MSPH 
  
  Release Date: November 9, 2020
  Expiration Date: November 9, 2023
  
  Disclosure Information:
  
  Planners:
  James Willig, MD, MSPH
  Professor, Infectious Diseases
  
  C. Haddon Mullins, IV, BS, BA
  UAB Medicine
  
  Jill Deaver, MA, MLIS
  UAB Medicine
  
  Adam Roderick, M.ED.
  UAB Medicine
  
  Anne Zinski, PhD
  UAB Medicine
  
  Caroline Harada, MD
  Associate Professor, Geriatric Medicine
  
  Ronan O’Beirne, EdD, MBA
  Director, UAB Continuing Medical Education
  
  Katelyn Hiden
  Physician Marketing Manager, UAB Health System
  
  The planners have no commercial affiliations to disclose.
  
  Presenter:
  James Willig, MD, MSPH
  Professor, Infectious Diseases
  
  Dr. Willig have no financial relationships related to the content of this activity to disclose.
  
  There is no commercial support for this activity.
  Submitted By: Kate Hiden
• Transcription:UAB Med Cast is an ongoing medical education podcast. The UAB division of continuing education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA category 1 credit. To collect credit please visit www.uabmedicine.org/medcast and complete the episode’s posttest.
  
  Melanie Cole (Host):  Welcome to UAB Med Cast. I’m Melanie Cole and today, we’re discussing clinical encounter. In this panel, are Dr. James Willig. He’s the Assistant Dean of Clinical Education at UAB Medicine and Dr. Haddon Mullins. He’s a General Surgery Resident at UAB Medicine.
  
  James Willig, MD, MSPH (Guest):  Greetings and welcome to the next edition of our podcast on medical education. Today, we are going to discuss a little bit more about the clinical encounter and the steps that you can use as an educator as you interact in a room with a patient and your students. Last week, we talked a lot about the preparation before you get into the room and today, let’s really talk about the particulars of what happens in the room. So, again, I’m James Willig and I’m here with Haddon Mullins. Haddon is of course, our resident expert who has reviewed a lot of the literature for us. And today, we’re going to start – we are going to follow our format here with just a few questions and today I’m going to be asking the questions to Haddon. So, Haddon, initially, the sort of the question is, is there a plan that you follow generally for bedside rounds? And this is a question that you’re asking a clinician. For me, generally, I think of bedside rounds really as sort of a sequence of three things.
  
  The first is you walk in. There’s the greeting. There’s how are you today? Taking the moment to take the room in to look around, to see the family, to see the person, to see if there’s any clues that they are in distress or kind of what’s the status of the situation right now to see if there is anything that you need to respond to immediately. Assuming that things are well and things are okay, then we’ll produce to what I’m just going to refer to sort of the data sharing portion of the encounter where the student or the resident will really review the data from the last time we saw that person, get all the data from the previous night, discuss the data from today. Typically, that’s SOAP format and ultimately, we’ll really go into the assessment friend version of that SOAP format where we really discuss the management. And really tell – make sure that people know what’s coming now in terms of today and what’s coming – what’s the long term plan that we are working towards. But that’s about as much as I do in terms of having a general plan or outline for what’s going to happen in the room. What does the literature teach us?
  
  Haddon Mullins, MD (Guest):  So, there’s a number of ways that the literature deals with what to do when you are inside the room with the patient and your whole team is there. Like you said, what we talked about last week was more about preparation before you step in the room. And this would be from the moment you walk in to the moment you leave. And an introduction is a perfect place to start. We talked a little bit about orienting the patient last week and acclimating them to an academic environment and if that’s already been done, the introduction can be brief. If not, you can – we can revisit some of those aspects of the introduction including introducing the entire team, telling them why you’re here, and that this is an academic experience. There will be education going on, but this is also first and foremost about your care plan.
  
  The introduction is a great place and the introduction, and the closing will be the only aspects of the encounter that the Attending leads. And so, this is the Attending’s moment to role model physician patient interaction, and professionalism to the students and the residents.
  
  Another option if you feel that your residents are prepared to do this, you can allow the house officer to lead the interaction and that’s beneficial because the resident is most often the patient’s primary doctor and it allows you as an Attending to step back and better observe team interaction and provide better feedback from the encounter itself. So, if you have the resident leading this and doing the introductions, then instead of role modeling professionalism and the physician patient interaction; you’re observing your resident and then you can give your resident feedback as well.
  
  Dr. Willig:  Interesting.
  
  Dr. Mullins:  So, before I get into my recommendation, like I said, it’s an amalgam of a couple of different recommendations, are there any priorities that you have particularly during the case presentation or the data sharing portion?
  
  Dr. Willig:  My first priority is that the presentation is targeted at the patient and the family. So, the information has to be relayed in a way without jargon and it’s got to be relayed in a respectful and a direct way that’s inclusive. Again, patient-centered is the word that really should be underscored and highlighted in the case presentation. So, I would say that’s my first priority. My second priority is that we review, reconfirm critical history and physical examination findings. If there’s a detail in the history, maybe the sequence of symptoms or the severity of symptoms or an associated symptom that might lead us to consider something different in the differential; that would be a piece of data that I would want to reconfirm at the bedside. So, key decision making pieces of data I’d want to reconfirm. As well, as any abnormal physical exam findings. I think it would be a great opportunity to sort of have the student demonstrate what they have seen and have the Attending confirm them. If a physical exam finding is there and it’s interesting; it’s something that I often get the entire team to listen to while the presentation can be going on you might say okay, let’s walk away here and keep presenting. Make sure that the patient agrees and is okay with the student doing it and then maybe have the students line up and look at or auscultate a specific finding that was found there.
  
  So, first, patient-centered presentation. Second, review of important history and physical exam and the third priority for me is that we really answer all of the questions from that patient and their family. Again, if we leave questions in the air, I really specifically say I don’t think we’ve done our job well enough and if folks need to know the plan immediately for today, as well as long term, this is what we are working toward. We think that disease pattern A or B might be going on. We continue to work towards differentiating those two patterns and today’s tasks are one, two and three. That sort of – I want people to really know what we’re doing and why we’re doing it. But that would be the priorities for the case presentation.
  
  But now, what does the literature show us?
  
  Dr. Haddon:  Those are great priorities for a case presentation in general especially trying to limit the medical jargon and of course being patient-centered. As an Attending, there are a number of things that you can be focused on and the person presenting the case first of all, can be anyone from the student to a resident. And so these same aspects or techniques kind of apply to any student at any level, any learner at any level. And I found five I’s that a teacher can use to think about where his head should be while the case presentation and the data sharing portion is coming from the learner. That includes the introduction, which we have already covered, in the moment included focused listening, eye contact to the patient and the student, nonverbal cues. A lot of times, learners can be uncomfortable or uneasy or nervous about case presenting and for them to be able to look at the Attending and you give them a slight nod, they know you are listening, they know they are going in the right direction and everyone moves forward more smoothly.
  
  Dr. Willig:  Just a point on that is certainly more contemporary rounding when you have both pagers and smartphones, that people have access to you continuously; I can’t remember the last patient presentation that I got through entirely where I didn’t get sort of three things buzzing on my person. And it’s messages from all kinds. So, I think it’s important to know that word focused listening, to really, while you are in there, just really be looking at the patient and try to leave all of that external stuff to the side. Leave the phone in your pocket. If your pager rings, just kind of reach over and silence it and continue. Don’t even break eye contact if you do that. That’s something that someone highlighted to me as a behavior that they saw a physician do when they were speaking to them that really to them, it meant wow, this person cares so much about me that they are not even looking at their pager right now. They’re really sort of attentive and they are in me. And all the clinician did was kind of reach over and silence the pager and continue that encounter. So, that attentive listening and being in the moment is key.
  
  Dr. Haddon:  Right and that goes in with another I which is interruptions, particularly meaning to minimize them and that’s exactly what you just said to minimize as many distractions coming from pagers or anything else that might be going on and an important part about that, is to establish beforehand if you can, circumstances to the learner in which you might have to interrupt and that would include anything from certain emergencies, time constraints, if you want to clarification, if something is disorganized. And so that would let the learner know that we are not going to interrupt your case presentation except under these particular circumstances. And it let’s them know ahead of time that if you’re going to interrupt, it’s something that I as the case presenter, need to hear.
  
  Another I would be inspection. And this will line up with our next step which would be the physical exam. The Attending can be acutely aware of the data that is being shared, the psychosocial aspects of the team and the patient and periodically be glancing at the patient. If the student is mentioning certain physical exam findings, and the Attending can point out certain things about the patient just from observation, that will be relevant to the physical exam findings; then that can help the Attending better prepare for the physical exam demonstration. It can also be a great opportunity for an Attending to show students the power of observation and if you as the Attending, have been inspecting the patient while listening to the data, you have an idea of what’s going on and you’re also practicing observation; then you as an Attending can show the students or the learners this is what I’ve learned just from that case presentation and just from this observation, before you’ve ever even touched the patient. And it can be an opportunity to show the power of observation.
  
  Dr. Willig:  This is very interesting to me. Because, moving to bedside rounds, and when you hear a presentation, and to have the opportunity to observe the patient while things are being presented; there seems to be some additional insight available there. And that insight is of course, comes from just watching the patient and watching sort of their demeanor and their status and are they in pain, or acutely ill, not acutely ill. There’s all of that clinical insight but there’s another level of insight where you can really look at how did they respond when different facts of the history were said, you can get a sense for are they really anxious about what’s going on, are they really concerned, are they really worried. Are there parts of their history where they seem to have a strong reaction yes or no? And you can even take a moment to really look a little bit more broadly than the patient and look at the next concentric circle around them, the people around the bed, their family or friends or whoever is there with them and see how things are affecting them. Sometimes, you’ll sort of see this look of anxiety when something is mentioned and you can understand that yeah, that’s – you can intuit that that’s probably something that they were talking about. That’s something that they’re worried about and they’ve been mentioning it, they kind of reacted to it. So, there’s a ton of information. There’s looking around the room. You walk in, you see what candy wrappers are lying around for example that are going to inform discussions that you might have about changing dietary habits or things like that.
  
  So, there’s just a wealth of information lying around right there in the room. And I think using that time for inspection, while the case is being presented at the bedside, just is a whole – just a bunch of insights can be gleaned there.
  
  Dr. Haddon:  And it’s important in the sense of efficiency as well. And to prepare you for whatever discussions you might want to have with your learners or patient going forward. So, that was four I’s, introduction, in the moment, inspection, interruptions, minimizing interruptions and then the fifth can be independent thought. And this is I believe you said it last week but it’s important to have the students commit to a differential in the room before you give them a kind of hint or it the differential has been established, the plan and that needs to be done because it can allow for a couple of things. One, it can let you as the Attending know where the learner is and what knowledge gaps that you might want to fill in and it allows for the student, themselves to guide the teaching points. So, if they commit to a certain differential, or a certain plan and you already in your head are thinking either that’s great or you know where their head is at so that you can direct your teaching points specific to where their needs might be in terms of management or diagnosis.
  
  Dr. Willig:  This is so key. Right. Because this is the – that alchemy that we have to achieve where we have all of these concepts that we know in terms of how to illicit this data, then how do you organize those pieces of data into information and sort of spin that into an insight? So, as a student, then you need to encourage your students to do this. They have to independently come up with their differential. They have to come up with their assessment and plan. It doesn’t have to be accurate. It needs to be done. It is born from repetition and it is this task of taking this data, interpreting it, and sort of changing it into a treatment plan, a diagnostic plan. That’s the crux of our profession. And you’ve got to start getting your repetitions in.
  
  Sometimes it is see students be worried or be overly worried about am I going to be wrong, am I going to look bad. They make a point of reading the resident’s note or the intern’s note and then go in to write their assessment and plan. I make a point of freeing my students from that burden. It says the exercise here is for you to do this. For you to get your practice. After you do it, you can maybe look and those plans and then go read some more, but I want to hear what you’re thinking. Because if I know what you’re thinking and where you are at, then again you have set the level of where you are as a learner. And then I can work targeting where you are to lift up your level. But if I don’t know where you are, then you’re telling me you’re kind of transcribing what was in the resident note or in the intern note, I know nothing about you as a learner.
  
  So, you have to really emphasize, it’s okay. I want to hear your plan. I want to hear where you’re at and go from there.
  
  Dr. Mullins:  Right and that’s perfect. And it’s very important and it’s mentioned in a number of articles about the importance and a number of these teaching based strategies to have the student commit to a differential. Now, the case presentation is over. I think the next important step is demonstration of a physical exam finding. And that can be more than likely relevant to the patient and their condition. Even if the exam findings are unchanged, I still think it could be important as an Attending to demonstrate a certain maneuver in front of your learners. Is this something that you do regularly or is there a strategy that you have for demonstrating physical exam findings?
  
  Dr. Willig:  So, it makes me think what I hear you note this that there really are physical exam findings that are going to be evolving during the hospitalization, say the percussion or an effusion in the lung and ultimately after a thoracentesis, or another procedure; the fluid is gone and you see that exam evolve. The evolution of physical exam findings associated with acute exacerbation of say heart failure with a reduced ejection fraction. How do those physical exam findings evolve over time? So, I think there’s a lot of value in picking a couple of threads in the physical exam that are going to evolve over time and going back to them every day to give folks an idea of how these things are expected to evolve.
  
  Sometimes it’s as simple as look at the ease with which the patient is breathing every subsequent day in someone with an acute exacerbation of chronic obstructive pulmonary disease or something like that. And then the other thing is sort of these one off physical exam findings which I often use to sort of introduce topics of discussion where I might have seen something yesterday and I might have said oh wow, look at this person has an interesting physical exam finding and it might be something as simple as look they have what I believe to be onychomycosis and look at their age and maybe the next day, the teaching point might be heh, look at all of these things that can mimic onychomycosis in someone this age. So, just don’t talk about that possibility.
  
  Or sometimes, the other teaching point that I might make would be heh, let’s really talk about distinct presentations of onychomycosis and how some of them are associated with or have been associated with immunodeficient states or not. Here’s wide superficial, here’s proximal, here’s distal lateral onychomycosis and certainly there’s different associations with particularly the wide superficial and the proximal have been associated with some acquired immune deficiency states. But again, the point is, I’m going to use a physical exam finding as a gateway to make another teaching point or I’m going to really talk about how that physical exam finding evolves over time. And on either of those scenarios, demonstrating the appropriate technique of how you elicit that physical exam finding is crucial.
  
  Dr. Haddon:  Right and so, I think a key part of this is that this is a demonstration. So, this is not from what I read in the literature an opportunity for assessment. I think it can be afterwards if you feel that you have the time or the inclination to. But it should be led by the Attending as an expert and this is how this is done as opposed to a chance to have a learner do it and then you give feedback. I think it’s more important or one important aspect of a learner learning how to do this is to observe an expert actually performing it while describing it.
  
  So, there’s a model to do this called the five minute moment which was developed out of Stanford. The paper is G2016 and the whole idea is that you can demonstrate a physical exam finding in five minutes or less. So, the idea for it is to first provide a contextual framework. This works perfectly at the bedside because the framework is already there, the patient with a certain physical exam finding. You can also provide historical context or a story of when this particular finding was of importance in terms of a diagnosis that you’ve had in your past or this is our patient right here with this problem with this physical exam finding.
  
  So, a framework and textual narrative, demonstration by the Attending and then as you were saying, it’s important to talk about how to interpret it and then what are common errors or what else could this look like, or how do you differentiate this particular interpretation from that particular interpretation and how to use this physical exam skill to help your diagnosis. And this technique, the five minute moment, can be used independently of this whole case presentation but I think it also fits very nicely within it. Mainly because you have a context, you have a purpose, you, as the Attending are in there with your learners and it let’s you again, model your relationship with patients and you’re modeling professionalism.
  
  Dr. Willig: And then you discuss the interpretation of it and the common errors associated with it.
  
  Dr. Haddon:  Yes.
  
  Dr. Willig:  So, that’s kind of the package for it.
  
  Dr. Haddon:  Right, that would be an easy way for you to work physical exam skills practice into your bedside rounds by you demonstrating.
  
  Dr. Willig:  So, let me talk about a practical concern here. So, at this point, I happen – I’m a subspecialist in infectious disease and I might not be – my cardiovascular exam might not be the greatest cardiovascular exam or it’s maybe – I would say not as good as I was when I was sort of hardened in the trenches, third year internal medicine resident. So, we work with people like that. That are incredibly skilled residents that have seen a great volume, maybe they just rotated off of cardiology rotation and they have all of this great information for us. What you’ve read here, really talks about the Attending demonstrating a physical exam finding and go on, did you see instances where you could ask a resident to lead the physical exam finding? Because frankly, in my case, I’ve seen it over and over. There are residents that are really great at parts of the physical exam whereas I might be okay at them.
  
  Dr. Haddon:  Yes, absolutely. And the residents as we’ve talked about, can be just as integral and should be viewed as teachers or Attendings in terms of how junior faculty or students view them. So, yes, absolutely. And that’s a common concern among Attendings. I can’t remember the exact paper, but that was a common concern about going to the bedside in terms of Attendings not feeling like they were equipped to demonstrate certain physical exam maneuvers. And I think it makes sense, and I think there are definitely people who are better at one skill than the other. But I also think the Attendings main advantage would be in the contextual framework or giving a historical narrative or giving some kind of a story to say heh, this is when – this was a case that this particular physical exam was really important or this is when I learned this for the first time or this is a history or a story from my own training. That can be important for students to give them a relevance for these types of maneuvers and why they’re being done and why they make you do it every single time you go to the room and you’ve never actually seen or found anything.
  
  Dr. Willig:  So, [00:22:30] is sort of the case in your experience?
  
  Dr. Mullins:  Right. Exactly.
  
  Dr. Willig:  Okay.
  
  Dr. Mullins:  And I think in terms of a – from a learner’s perspective, it can also be important to see the Attending interact with the patient as well. But as we’ve talked about, the resident could and should be seen as an acting Attending. So, yes, absolutely the residents can demonstrate this as well if they know the framework and if they’ve been taught the framework by the Attending or someone that’s familiar with it.
  
  Dr. Willig:  Okay. So, Haddon, you’ve told us a lot about sort of preparation and teaching at the bedside, but it looks like you also reviewed in the literature, several sort of published frameworks for teaching at the bedside. And I know that you want to share some with us now. Tell us about what you encountered that you found a lot of value in.
  
  Dr. Mullins:  Yes. So, there are a couple. Well there’s three really main ones. There’s a lot of literature papers that will give an outline of how to do a bedside encounter. This is what you should do. These are the steps you should take. But there are really three main mnemonics or teaching points that have really been established in terms of this is how you teach at the bedside.
  
  So, this is after the case presentation, after physical exam finding, okay, everybody is looking at you as the Attending to teach something. Or to tell them something that they need to know. One is called the one minute preceptor. Another one is called SNATS. One minute preceptor is very well established. It’s easy. And it’s very quick and simple. SNATS is another one that tried to expand upon the one minute preceptor, and it was really more – tried to make it more student-centered as opposed to the one minute preceptor which is more Attending-centered.
  
  The problem with both of those in terms of our discussion is that both of those are based mostly on outpatient care. So, Dr. Stickrath out of UC Denver wanted to come up with a plan for teaching for an inpatient setting. And so, he looked at the one minute preceptor, looked at SNATS and based a lot of this on adult learning theory or constructivism and came up with MIPLAN, M-I-P-L-A-N, meeting, which we have covered, introduction, which we have covered, and then plan which covers your teaching points.
  
  Dr. Willig:  And meeting was working with your residents at the beginning of their rotation, establish expectations about what’s going to happen through the rotation and through bedside rounds and the routine day.
  
  Dr. Mullins:  Yes.
  
  Dr. Willig:  The introduction is really how we walk into the room, how we interact with folks within the room.
  
  Dr. Mullins:  Yes.
  
  Dr. Willig:  And then there’s the plan part.
  
  Dr. Mullins:  Yes.
  
  Dr. Willig:  Okay.
  
  Dr. Mullins:  Which is teaching points at the bedside.
  
  Dr. Willig:  Okay.
  
  Dr. Mullins:  P is patient care. So, your first set of questions should be patient focused and involves patient care, patient management, or diagnosis type questions. These can help you probe for student knowledge and identify student gaps, can let you assess their clinical reasoning and again, this would be guided by what they committed to originally. So, whatever their commitment for patient care was, those questions should come back off of that committed differential or plan.
  
  Dr. Willig:  So, you start with questions about like heh, here’s what you just presented. I want to confirm or clarify this in the history or I want to maybe look at this physical exam finding and do it independently, confirm it independently and then if you, the student commit to diagnosis, then you can sort of say okay well what did you commit to, why that, what do you think of that pattern. So, you hold your initial set of questions around there.
  
  Dr. Mullins:  Exactly.
  
  Dr. Willig:  Okay. What comes next?
  
  Dr. Mullins:  Then after you’ve established patient care questions and one important point for this is to try and involve the whole team so these questions could be graded up but it’s important never to downgrade the questions. So, if you are going to ask your senior resident a question about management and you disagree or think that’s not right, never to ask a junior faculty member that same question. So, you can grade these questions up –
  
  Dr. Willig:  Junior faculty or like a junior year student.
  
  Dr. Mullins:  Your student.
  
  Dr. Willig:  Your learner. Okay.
  
  Dr. Mullins:  Or an internal like if you are asking your senior resident a question about management and they get it wrong or disagree with what your own opinion is, don’t ask that same question to the intern. Because these questions aren’t meant to be competitive. It’s supposed to be educational. But you can grade up questions if you would like. So, you can go from student and say what is your committed differential, okay then you can ask your intern, well what would your differential be and go up to the senior resident. You don’t want to – especially because again, this is a different dynamic in front of the patient. You don’t want to undermine anybody’s authority. You don’t want to embarrass anybody. You want to make your learners comfortable sharing their answers without being nervous that oh I can’t get this wrong because a junior faculty member or a student might show me up.
  
  Dr. Willig:  And what’s interesting too is that sometimes I’ve – people as you’ve mentioned think gosh, I don’t want to get this wrong in front of the patient. That I’m going to look like I don’t know what I’m doing. And to manage that feeling, sometimes if I ask a question, I will – and I’m seeing my learners struggle a little bit, I’ll say something like it’s a great thing that we work in teams. And all of us work together. So, let’s kind of go to so and so, what are you thinking about this. And that’s how I’ll take my question on to the next level of learner and really not sort of say something like well it seems like you don’t know the answer so let me ask this other person over here. But rather just make it a smooth transition heh, we work as teams. And we share information to do it. So, I’ve heard what you have to say, let me include so and so in this discussion. And that makes it more of a transition as opposed – that isn’t in anyway kind of negative towards gosh you didn’t know that.
  
  Dr. Mullins:  Right and then it’s more of a layering of information as opposed to senior members being undermined by other members or and the junior members or the students don’t want to have to disagree with the senior members either. I mean as a student you’re probably going to just spit back out whatever the senior resident said. So, you want to grade up as opposed to going down. So, that’s questions from the Attending about patient care.
  
  Next step would be to ask your learners if they have any questions. We’ve had them commit to a differential and if they are allowed to ask more questions, they are allowed to guide the teaching experience even more and fell more involved as opposed to just a passive member. And that’s a really important part of the SNATS mnemonic and the MIPLAN mnemonic is to make this education learner-centered. And learner doesn’t just mean a student. It can also be an intern or a resident, but to allow them to ask questions and let them kind of guide what they would like to learn. It also let’s you as an Attending gauge where they are at based on what types of questions they are asking. And it allows you a chance to address specific problems or questions that your learners might have. This could also be done away from the bedside. Especially if there are questions of a sensitive nature or if there has been some kind of a psychosocial issue that your learners have questions about how to manage. Those types of things can be done away from the bedside. It’s important as an Attending to allow your learners to ask that question at the bedside if possible but I’m sure there are also practical time constraints and things like that, that you may not be able to answer every single question that your learners have at that time. But to give them the opportunity to say heh, this is what I would like to learn from this patient right now, is a good way as an Attending, to target your teaching points to where they are needed.
  
  That’s plan, PLA is Attending’s agenda. So, if you’ve established patient care questions let’s say there weren’t that many questions, this is hospital stay day ten, and everything is the same and you are looking to discharge, there aren’t that many questions, learners questions weren’t many or have been answered, then you can move on to your agenda. And you can say okay, this is a teaching script that I have prepared for this certain disease. This is this patient reminds me of a patient that I had during my training. Here is some literature that I have read recently on this particular disease. This could be a good opportunity to incorporate chalk talks or just to teach general rules.
  
  So, that would be after patient care questions, and learner questions is finally, when as an Attending, you can teach whatever you would like to teach until the learner has things that you think they need to know, they may not realize that they need to know.
  
  Dr. Willig:  This part, I’ve seen people do it in so many different and effective ways. I’ve heard people sort of talk about you almost have to have a lot of prepackaged content that you can share and with your learners at the bedside. I’ve seen folks have specific articles that help with the management of common conditions. I’ve seen folks have chalk talks or diagrams that were drawn to help people think through it. I’ve seen people have a thumb drive with some pictures of a physical – a cutaneous finding for example and there will be some teaching slides about it, or some questions associated with it. But this is really where as an educator, you get to kind of work on your portfolio and it builds over time and you have all of these great quick bedside teaching interventions that you’re going to have available to you, that you can use with your learners. It would be great to see something like an online resource where people can sort of maybe it already exists, but it would be – this is a fantastic – there’s a fantastic set of resources around there if you take a look around and you see what your colleagues are doing. It’s a great way to really build up your own arsenal and portfolio of educational interventions.
  
  Dr. Mullins:  Right. And I hesitate to give particular specific advice on this because I feel like a lot of Attending teaching points probably grow and develop organically just over the years of seeing certain disease patterns over and over and over again. Or being familiar with the literature around certain pathology or certain treatment or certain plans. And so, there really is no prior experiences, citing literature, chalk talks. I think all of that works in its own way and personally, I think it works even better if it comes from the Attending as opposed to being dictated by someone else. So, I fell like, as a teacher, the Attending is going to be more enthusiastic and more involved if it’s something that they have developed themselves as opposed to something that comes from some kind of protocol.
  
  Dr. Willig:  Yeah, and you make a very good point about how a lot of these things, we can think about the mass option, let me show you causes of pathology A. but there’s a lot of teaching that doesn’t have to be just knowledge about a pathology. There’s interactions about here’s how I work through that difficult encounter. Or here’s how I usually go through a conversation where I have to deliver difficult news. Or here’s how I navigate a difficult interaction between two family members or gosh I had a suspicion that there was something amiss, maybe I suspected it was spousal abuse, and how did I navigate that and have the opportunity to speak to the person individually. So, there’s a lot to do and teach beyond just here’s some great insights into the latest and greatest therapy or knowledge of the pathophysiology for condition A.
  
  This is really where you get to share a lot of your professionalism to model how you do things to even if a consultant comes up, how do you interact with the consultant, how you interact with the nursing staff. One thing I always like to say is that whatever you do as an Attending, makes it permissible for everybody else to do that.
  
  So, you really have to manage your professional relationships in a very high level way as you go through with learners around you. Because everything they see you do, you have just made permissible and your normalize that behavior. So, even ill comments about gosh, someone came from a [00:35:18] hospital and look at this poor job that I think the people over there did. Even that’s problematic. It can be framed as heh this person is here now. We understand how it was done before. Now we really have to make every decision going forward based on our knowledge and what we feel is the best course of action here.
  
  So, there’s so much that you need to be aware of as an Attending. And there’s so many times where you teach intentionally but you also teach unintentionally when people just observe you going through your things.
  
  Dr. Mullins:  Right and it’s important to remember that all of this is happening with the patient. So, your agenda for the day could be patient education. Or it could be further interaction with the patient. This is an opportunity. It is important for you to teach your learners. And so that’s where the patient care questions and the learner’s questions comes in but here, the A, Attending agenda is your agenda as an Attending. So, if you want to address the patient, if you feel like your learners are doing well or that you’ve established or done enough teaching with the first two sections and now here, we are; that can involve anything from patient education to more history from the patient to talking with the family to teaching scripts.
  
  Dr. Willig:  Yeah, no this a beautiful point because modelling teaching to the patient and how to you get folks on that path towards behavior change, needed behavior change; is another thing that we can model very effectively. And people will come up with all interesting ways. I saw a colleague of mine interact with somebody who was a plumber and the person had come in very late, after many, many weeks of symptoms for the specific condition that was bringing them in that day. And the idea was to really communicate to this person, listen, you’ve got to come in at the first sign of trouble. So, they kind of tried saying that about the condition and really wasn’t getting much traction. And then they kind of just started talking about – so tell me about the work you do. Oh, you’re in plumbing. That’s great. And kind of talked a little bit about that and then started talking about so, if something is wrong in my house, and I see sort of a wet spot in the ceiling, but it’s kind of small, should I just leave it there and call you a week or two weeks from now and all of that and the person said no, that would be ridiculous. You want to call me right away before there’s a lot of water damage. And then they kind of stopped in the midst of that and they looked at the provider and said, oh. And that was the way. That was the way to explain buddy, you can’t wait three weeks to come in when this is going on. You got to come in early. So, that was a very interesting interaction. I remember learning a lot from them because that was a very clever way to sort of understand that patient, their life, and really frame the message to get them to embrace the needed behavior change in the context of their life.
  
  One last thing I want to challenge our learners to do is something that I actually did the last time I was on the wards. So, I kept a sheet of paper in my pocket and every day, I jotted down what I taught about on rounds. And my goal was to sort of do three things every day. So, it’s a lot of patients. And there’s a lot to teach and I think I started jotting down even if it was discussed today, I taught about this topic. Or I really went ahead and had a difficult conversation where I shared a tough diagnosis with someone and their family and then I went outside the room and sort of reviewed what was my strategy, this is what I was thinking when I saw their face, when they reacted this way, I decided to take the conversation here and that’s teaching.
  
  But go ahead and try that sometime. I encourage our listeners to just kind of keep a log of what you do for just a week. Just do it for a week. And get an idea what are the things that you are teaching your learners and it also made me a little bit more aware that every day, gosh I wanted to at least three things. we are not going to get out of rounds focusing on three things. It also allowed me to kind of double back on lessons that I felt were particularly important that I wanted to emphasize because I saw another missed opportunity where that lesson could have been used in a conversation with a patient or a family member.
  
  Dr. Mullins:  That would be perfect. And I think the advantage to having a mnemonic like PLAN in mind is simple but it’s not strict. So, it lets – it gives you the facility and the flexibility to teach in your own way but it keeps it first of all patient-centered and learner-centered and then allows you as an Attending to kind of wrap things up and frame things in a certain way that you might believe is outside of where your learners might see it. To give your insight in terms of they might not recognize that they need to be asking this question is where I can step in and show them what they need to know that they don’t know they need to know.
  
  That’s PLA, N is next steps. And before I get into next steps, he makes a point that next steps could be just to move on, say we’re done with this patient, we have a lot to do, we’ve asked questions. Everything is good. The patient is good. Let’s just move on. So, next steps can be just that. But if not, one big part that I kind of adapted from another plan so is to give a learning prescription. And so we call them topic reviews. And it’s mentioned in here, but it’s not really detailed out and I found this format that I thought was really interesting that was applied to a different type of teaching strategy, but I think it also applies well here. And that’s the PICO format. And it’s actually supported by PubMed and you can use a mobile app on your phone to use this format to search PubMed for questions.
  
  Dr. Willig:  PICO?
  
  Dr. Mullins:  PICO, P-I-C-O.
  
  Dr. Willig:  Okay.
  
  Dr. Mullins:  And there are a number of people that have – it was originally designed by PubMed for systematic or for asking questions for systematic reviews but then there were a number of people that said heh, this might be a good way to ask clinical questions. And there was a group of physicians paper is Nixon 2014 that applied this to learning prescriptions. And there’s some other people that have applied it to learning prescriptions and they found that using the PICO format, you get a better quality answer from your students. Also, another important part about learning prescriptions is to keep them concise and narrow and that it is better to ask a specific question as opposed to saying why don’t you go do a topic review about heart failure.
  
  And then they come back with a dissertation on heart failure that nobody has time for. And what did they really learn, nothing that they didn’t learn in the first two years of medical school. The PICO format is Patient Intervention Comparison Outcome. When you are asking a question, it involves a certain patient set, an intervention, a comparison to another type of intervention and then what your desired outcome is. And it’s best suited for therapy questions but can be used for questions related to etiology, diagnosis, harm, prognosis, prevention, cost analysis. You can still use the same kind of format and adapt it a little bit.
  
  Dr. Willig:  And it’s patient intervention comparison outcome?
  
  Dr. Mullins:  Yes.
  
  Dr. Willig:  So, let me throw a clinical question at you and see if you PICO it.
  
  Dr. Mullins:  Okay.
  
  Dr. Willig:  So, today we saw a patient and they’re having shortness of breath. It turns out that they have a genetic condition that makes them hypercoagulable and they have a history previously of having lower extremity clots that have sort of broken off and caused a pulmonary thromboembolism. And the question we need to ask is gosh, do we need a VQ scan here or do we need a CT Angio or something like that? Or which imaging study should we go after? So, how would you PICO that?
  
  Dr. Mullins:  Right. So patient would be your patient with that condition, it can also include the type of genetic disease that they might have if that’s relevant. Intervention would be what test you want to order. And the comparison would be compared to another type of test that might give you similar data or similar information. They don’t have to be related tests, but related to –
  
  Dr. Willig:  It would be contrasting the tests as to fata, specificity, cost, accuracy, those types of things.
  
  Dr. Mullins:  Right. And then outcome would be what do you want to know. Is this you are trying to determine a certain diagnosis, you’re trying to determine what kind of treatment plan to follow, you’re trying to determine a prognosis. That could all be what your desired outcome would be.
  
  Dr. Willig:  So, this is very interesting because a lot of times, I’ve sort of varied how I have done this over the years. Initially, I think I was much more general, like heh, tomorrow why don’t you come in and teach us a little bit about condition X. And I got a couple of dissertations and all of the sudden, it was like we don’t have 15 minutes on rounds to talk about condition X. So, over time, I basically said things evolved into more like tomorrow you are going to have three things, or you are going to have three minutes to tell us the three most important things about condition X or give us a general description of this condition.
  
  And I think it felt even better if you say something like we’ve got to make a clinical decision tomorrow. And that clinical decision is going to be whether we are going to use treatment A or treatment B. And I need you to go tonight and I want you to review what our patient is, think about the specific intervention, compare the two interventions that we’re talking about and what our potential outcomes are going to be. And on rounds, you’re going to bring those data in and we’re going to – you’re going to inform the decision that we’re going to make tomorrow. If the clinical scenario lends itself to waiting, if it's that time for decision, what a wonderful way to include your student as an active participant in the medical decision making in terms of informing that decision and to give them a targeted format on which to look at the information.
  
  Because it’s also medical students that are our learners are busy as well. So, when you tell them go read about condition X, well, I can probably read about any condition for a little amount of time. But if you give a specific question, you’ve targeted me, and I can really get you a well flushed out answer with a format like PICO.
  
  Dr. Mullins:  Right. And the great part I think about PICO is that it’s PubMed supported with a mobile app. So you can –
  
  Dr. Willig:  What does that mean?
  
  Dr. Mullins:  So, you can go to PubMed, you can type in on your phone PICO PubMed and it will come up as a mobile website or app that has patient intervention comparison outcome and you type in each one in it’s search and it searches PubMed for you. PubMed Medscape. So, it will do it for you. It has the format already established for students that you can do on a mobile phone.
  
  Dr. Willig:  I have never heard of this. This is very interesting.
  
  Dr. Mullins:  And originally it was designed like I said, for systematic- for asking systematic review questions or asking questions to write systematic reviews. And it’s recently being applied to the world of education and making these learning prescriptions for students and giving them targeted answers that can get targeted and relevant answers. Target questions to get targeted answers.
  
  Dr. Willig:  That’s awesome. That’s awesome.
  
  Dr. Mullins:  So, that’s PICO. And that would be applied on the last part of the plan mnemonic if you feel like it’s needed or if it’s relevant.
  
  Dr. Willig:  Or it’s an option for you.
  
  Dr. Mullins:  Right, it’s an option.
  
  Dr. Willig:  So, you have hit us with a lot of mnemonics today, sort of MIPLAN and PICO and the five I’s. what would you tell us here to close to wrap up? What are the key take aways we should have today?
  
  Dr. Mullins:  I think that what I came up with or what my recommendation is for inpatient rounding is to use the MIPLAN mnemonic which covers what we talked about last week and today from the meeting to the five I’s during the case presentation, to the PLAN mnemonic for teaching. Where I added or mixed in would be to be sure and include a physical exam skill which you can use the five minute moment for that I mentioned and that’s going back to our original definition for bedside rounds which was that is includes the demonstration of a physical exam skill. So, that’s something that’s not included in MIPLAN, but I think should be included in a bedside encounter. I also think if you are going to give your students or learners a learning prescription or a topic review; that to provide them with this PICO format will not only give them a better direction, but it will give you as an Attending, a better answer as well.
  
  Dr. Willig:  And ultimately to better and more focused patient care and a better discussion at the bedside.
  
  Dr. Mullins:  Right.
  
  Dr. Willig:  And give the patient, the student, the learner just a way to influence decisions. Because sometimes our learners we hear, gosh, a lot of this discussion is high level or I don’t feel like I’m part of the team but a learning prescription with a PICO question that’s going to result – it’s going to inform a decision the next day, they can easily put a line from their effort that night to a clinical decision the next day, making them feel included in the team.
  
  Dr. Mullins:  Right. Exactly. So, after all of that, this is the clinical encounter would obviously include a closing which should be patient-centered as well. So, and we’ve talked about this a little bit but just to summarize it you would summarize for the patient, make sure they don’t have any questions or that you have answered all their questions and have a genuine closing and again, as I mentioned at the beginning, the introduction and the closing are really where you as an Attending, are going to model this relationship for you. Or the resident. And if you want the resident to do it, then you as an Attending can sit back and then give your resident feedback on how the closing was, how the introduction was. How the demonstration of the physical exam was. If they are not ready, then this is your opportunity to show them how it’s done and I think this clinical encounter covers a lot and give you a lot of opportunities to educate but I also think that it allows you to keep your care patient-centered and patient-focused at the same time. And that’s really the problem or the question is how do I educate and keep this learner-centered while also keeping my ultimate goal of care management patient-centered? And I think the MIPLAN mnemonic does a great job of that and I think that adding on of demonstrating a physical exam finding compliments that and I think the learning prescription add on also compliments that as well.
  
  Dr. Willig:  Say real quick the key elements for a closing.
  
  Dr. Mullins:  So, the closing would be to summarize concisely for the patient, avoiding medical jargon, what you have talked about and what your plan is for that patient. It would also include summarizing for the learners what they have learned and turning to them and saying this is what we talked about, reemphasize a learning prescription if you have one. Then you want to make sure you’ve answered any questions that the patient has and make sure that they and their family are clear with what the plan is and that they feel comfortable with that.
  
  Dr. Willig:  All right. Then with that, we will transition to closing our session today and I’m really looking forward to the summary of the key points here. I think there’s a lot of great things to reinforce from these mnemonics and their elements in our key take away section.
  
  Dr. Mullins:  Yes sir and our next session, will be focused on giving feedback.
  
  Dr. Willig:  Fantastic.
  
  Dr. Mullins:  Thank you sir.
  
  Dr. Willig:  Thank you.
  
  Host:  And a community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. That concludes this episode of UAB Med Cast. To refer your patients or more information on resources available at UAB Medicine, please visit our website at www.uabmedicine.org/physician. Please also remember to subscribe, rate and review this podcast and all the other UAB Medicine podcasts. I’m Melanie Cole.
• Hosts:Melanie Cole, MS