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Family Medicine Project: OUTLINE

Goal The project has two goals:

1. To develop your skill in critically approaching a health challenge from a family medicine perspective, which may be faced by an individual or a community;

2. While working on their projects, students will have in mind that their work should help their preceptors care for the identified individual or community.

Objectives By the end of this project, students will:

1. Carry out an in-depth study of an identified health challenge, on either an individual or community level. 2. Go beyond a strictly biomedical approach to their patient‟s or community-based health challenge. 3. Explore and critically appraise the available evidence and community resources, relevant to the identified

health challenge. 4. Use a collaborative approach, by involving the patient &/or representatives of the community, in developing

recommendations that will be feasible and acceptable to the individual &/or community. You are required to complete and present a project from the following two options:

Option 1: Individual Study The purpose of this project is to apply the patient-centred clinical method to a patient with an unresolved health challenge. Once such a patient is identified and interviewed, with assistance as needed from their preceptor, the student will create a clear question for further exploration (Health Challenge). Using both their own interview(s) of the patient and the preceptor‟s knowledge from prior encounters, the student will seek to understand the patient as a “whole person” and explore relevant community context issues that might impact management of the health challenge. (see below) The student will find, review, and critically appraise relevant, peer-reviewed literature and community resources. The student may need to arrange additional interviews with the patient to gather additional contextual or other patient information. Using these findings, as well as their understanding of the patient‟s illness experience and context, the student will pursue ―Putting it Together: Creating Options‖. At a follow-up visit, students should present their literature and context-based options and seek common ground with the patient in terms of defining the health challenge, establishing goals of management and identifying roles for patient and doctor. This follow-up visit is crucial to explore the appropriateness and acceptability of the student‟s recommendations, so they can realistically report on ―Next Steps/Common Ground‖. Example: Leonard is a 67 year old man, recently retired from his work as a labourer in the oil sands because of disabling dyspnea on

exertion. He lives with his wife, Anne and comes in requesting an increased dose of sleeping pills. Leonard was started on zopiclone 7.5mg at hs post-op a year ago, following TURP for high grade, localized prostate cancer. He’s finding little effect from the zopiclone for the past 3 months and describes sleeping for only 30 minutes after taking this medication. On further discussion, you learn that he takes the zopiclone at 4am. He later naps for several hours at a time, during the day and spends most of his evening hours, until 4 am, watching old movies, out of “boredom”. His wife has a more typical day/night pattern and Leonard explains that his current pattern has developed gradually over many months, worsening over the winter with the short days and cold weather making walking difficult . A quick screen for depression is negative but he does report smoking 15 cigarettes daily, as well as drinking 4-6 beers/day, 2-3 nights per week. This is much reduced compared to his “rig days” of 26 oz of rye/day or more when off work. He expresses interest in trying to get back to a more “normal” schedule.

From this case, a student might plan to learn more about:

-this man‘s ―context‖ eg. What is his marital relationship like? Why is he drinking so much? Why is he “bored”? Is the solution better sleep hygiene or something else (a spiritual or life cycle issue)? -evidence-based strategies for discontinuing sleeping medications and managing insomnia in the elderly -local community resources that this man might find helpful, depending on root causes of sleep concerns

With this information, the student would seek to find common ground with Leonard for management of his insomnia and zopiclone use.

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Option 2: Community-based Study The purpose of this project is for the student, with assistance from their preceptor(s), to identify a gap in care provision in their clinic or community. Once this gap is identified and explored, the student will seek solutions in peer-reviewed literature and community resources, critically appraise these and apply if suitable. If no appropriate solution can be found, the student will generate one. Students may have examined community needs in HPOP or MDCN 440, from a population perspective. This could be likened to a “top-down” point of view. In this project option, students will have the opportunity to examine a community need “from the inside” or from within the community, with the help of their preceptor. As one of the 4 Principles of Family Medicine states (see Appendix 5 of Core Doc), family medicine is “community-based”, meaning that family physicians interact with numerous individuals from their practise community (both patients and other care providers). Family physicians become part of the community in which they practise and have unique opportunities to identify community needs, based on these multiple interactions with community members, over time. Another of the 4 Principles of Family Medicine states that family physicians are a resource to a defined population and have the responsibility to advocate for the needs of both the individual and the community. Once the gap in care is identified, careful consideration of the “distal factors in context” may help in reflecting on relevant evidence and resources to generate realistic solutions that would qualify as “common ground” with the specific community in question. Example: A community project arose from a student seeing a patient with a severe sinusitis requiring hospitalization secondary to a dental abscess. The dental problem went untreated because of the family‟s poor financial situation and lack of awareness of low cost dental care services in the community. Using the same template slides, important elements of a project such as this include:

- description of the situation (“Health Challenge”) which stimulated the idea for the community project - review of the literature about what is generally known about sinusitis and dental abscess treatment - description of the patient community context, (e.g. prevalence and demographics of low income citizens, availability of dental care and barriers to access), focusing on any factors which may be contributing to this health challenge - review of the literature (e.g. might include income-related risk factors for dental abscess) and resources relevant to the health challenge and community context - description of possible community-based interventions or strategies for improvement - description of the barriers and facilitators to implementation and how these could be addressed - outline of which options are being or may be pursued in future, in the community. This student contacted dentists in the area and created a brochure outlining how to access low cost dental care and placed the brochures in the offices of local family physicians and emergency departments.

Project Presentation General Information 1. Preparation time:

It is important to discuss the project with your Preceptor(s) early in the first week of this Block. Each of these options involves a review of pertinent family medicine literature and will require preparation time. You are entitled to four half-days of protected time during the rotation to work on your project. You should not take more than 2 of these half days in the same week. Wherever possible, this should not interfere with important learning opportunities and the timing of this should be agreed between the student and the Preceptor.

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2. Resources and databases to consider for Literature search:

Several useful websites are housed on the UofC‟s Health Science Library website, under the Family Medicine Libguide at http://libguides.ucalgary.ca/family_med

3. Format of Presentation:

To pass this project, you must follow the attached template slides for the base of your project. Colours, graphics, pictures, tables etc… may be added as needed/desired. We encourage you to use PowerPoint (not pptx). Presentation time is strictly limited to 10 minutes with 5 additional minutes for questions and discussion. If you are using a Mac to create your Project Presentation, please alert the UME FM Clerkship Co-ordinator, so that they can assist with ensuring that any graphics you use are displayed as expected.

4. Submitting Your Project:

All project presentations must be submitted in electronic form, to the UME FM Co-ordinator at famclerk@ucalgary.ca on the Thursday prior to Wk 4 Friday. This will permit assigning students to rooms so there‟s variety in the topics presented, something that prior students identified as valued.

5. Assessment of Presentation:

This is a ―must pass‖ component of the clerkship and is also a required element of the Learning Portfolio; see FM Project Assessment form. Your project will be presented orally to your Community Preceptor (40% of Project mark) and where possible, to additional clinic physicians, staff and other health care professionals. Your Preceptor will provide you with feedback and complete the FM Project Assessment form provided with your Passport. Ideally, you will present to your Community Preceptor prior to presenting at Wk 4 Academic Day to your peers and 1 faculty assessor (40% of Project mark) and 2 peers (20% of Project mark). Project content is summative and presentation skills will be marked in a formative manner. In the case of a borderline or failing grade, your project will be reviewed by member(s) of the Family Medicine Clerkship Committee, on the basis of your Assessments and submitted slides (+/- Speaker‘s Notes). Suggestions for revision will be made, if necessary, and you will be given an opportunity to re-present later in the Block.

6. Opportunities for ―Fame and Fortune‖

Each block, students, Community Preceptors and Faculty Assessors are encouraged to nominate outstanding Project Presentations for a “Best Project” Award. A number of students have also used their Project Presentations as the basis of posters or other presentations at conferences, including Family Medicine Forum (October), the Annual Scientific Assembly (Feb) or the Canadian Conference on Medical Education (May).

This assignment has recently been revised, based on a formal study, the “FM Project Curriculum Evaluation”. Special thanks to:

Nathan Turely, MA (Sociology) & Research Assistant with the Dept of Family Medicine

All student, community preceptor and faculty assessor participants in this Evaluation

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Keys to Success in your Project Presentation

Follow the attached TEMPLATE SLIDES and use ppt (not pptx)

Take note of the FM Project ASSESSMENT form (see below)

Use the resources in Osler & Family Medicine Libguide http://libguides.ucalgary.ca/family_med

Stick to the 10-minute TIME LIMIT and be prepared to answer questions (5 minutes)

Present to your Community Preceptor PRIOR to Wk 4 Academic Day (and revise as needed)

Create a set of SPEAKER‘S NOTES, so as to avoid reading your slides when presenting

Create your slides once you‟ve made your Speaker‟s Notes and consider the rule of 8‘s:

maximum 8 lines per slide and maximum 8 words/line (see below)

Submit your slides to famclerk@ucalgary.ca 1-2 days PRIOR to Wk 4 Academic Day

Not-so-well-formatted slides… - large volumes of text invite audience (and presenter) to read from slides, not listen - consider a detailed Reference Slide at end of presentation

Better-formatted slides…

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FM Clerkship Project Slide Templates

Things to Consider: Create a title that is representative of your content, as well as sparks interest in your audience.

Things to highlight: -who does this problem affect? -in what ways does this problem affect the individual or community? Brief overview of FIFE -what has been tried so far? -what have been the results of these efforts?

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Things to Consider: -PICO structure to refine your question (Patient/Population or Problem, Intervention, Comparison intervention, Outcomes) -searching databases and journals that are relevant to Family Medicine, Population Health, and the identified health challenge -see http://libguides.ucalgary.ca/family_med Appendix 5 below -Level of available evidence (Sackett‟s criteria 1-5) and critical appraisal of resources used

Things to Consider: -Patient-Centred Clinical Method “PCCM”(Stewart et al, 2003) -Proximal factors in context: family, financial security, education, employment, leisure, and social support Distal factors in context: community, culture, economics, healthcare systems, socio-historical, geography, the media and ecosystem health -more thorough exploration of FIFE

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Things to Consider: Any features of the community which (may) have an impact on the Health Challenge, creating a barrier or a bridge to wellness. e.g. -availability of indoor recreation space, including hours, universal accessibility (wheelchair ramps), cost -community bylaws regarding snow clearance if health challenge -outdoor air quality related to agriculture or other industry

Things to consider: -revisiting your initial literature search (“What‟s known in the Universe”) and apply what you‟ve learned about your patient‟s key contextual features to refining and/or re-directing your search. -exploring government documents; community medicine, anthropology or sociology literature; community-based resources

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Things to Consider: -”benefits” may include reduced mortality, preserved function, improved quality of life, etc… -”drawbacks” may include financial cost, adverse effects of medications, time commitment, etc… -if available and relevant to your individual or community health challenge, include quantitative expressions of benefit/drawbacks, e.g. NNT, Absolute risk reduction

Things to Consider: -this should be done at a follow-up visit, after you‘ve searched the literature -PCCM identifies 3 Key steps to Finding Common Ground with patients: 1. ―Defining the problem‖ in terms that include both the disease process and patient‟s illness experience 2. ―Establishing the goals and priorities of management‖ putting the patients values at the forefront 3. ―Identifying the roles to be assumed by both patient and doctor‖ie. who will do what and what to do if the unexpected happens (safety nets) For a Community Health Challenge, outline specific interventions that you can justify to your peers that make sense for the health challenge and community context you‟ve presented and if possible, discuss these with someone representative of the community under study.

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Some concepts to consider when doing your project… A. Narrative Approach We all use stories to make sense of our experiences. The more stressful the experience, the more we need to tell and re-tell our story. When physicians listen intently, by using reflective methods and empathy, they build the patient‟s trust and can begin the process of healing. Phrases that invite patients to tell their stories, such as “Tell me, from when this first started, what you‟ve been noticing…”, give patients the opportunity to provide detailed information that naturally integrates the description of the disease process and their unique illness experience. A careful and active listener, who is skilled in this approach, can efficiently gather the information needed to understand “the whole person” (see below) while developing strong rapport with their patient. An excellent example of a patient‟s narrative can be found at: http://www.vancouversun.com/health/Cancer+best+thing+that+ever+happened/2752354/story.html B. Understanding the ―Whole Person‖ -requires integration of 3 concepts:

1.) Disease Process -the biophysical nature of the health challenge is revealed by conventional clinical methods which focus on History, Physical Exam, lab tests and other investigations.

AND

2.) Illness Experience -“FIFE”, an approach used in pre-clerkship Med Skills, can be used to think about an individual‟s unique experience of illness,

FIFE: Feelings about being ill (including Fears) Ideas about the illness-the patient‟s explanatory model and the meaning of the illness Functional impact of the illness Expectations of the visit/physician

(see Calgary-Cambridge Guides 1 and 2 (CCG), Appendix 2 and 3) AND

3.) Context: -many elements of a patient‟s context may be revealed by a conventional “Personal Social History”, including occupation, home situation and habits. The ―Patient-Centred Clinical Method‖ (PCCM) (Stewart et al, 2003), pioneered in the 1980‟s and ever-evolving, encourages a richer understanding of an individual‟s or community of patients‟ “context”. This typically requires several visits over time (continuity of care really helps here…) and preceptors may be able to provide much of this detail.. The PCCM recognizes the key role of:

a. Proximal factors in context include personality, current life stage, past experiences, spirituality, family dynamics, financial security, education, employment, leisure, and social support. b. Distal factors in context include community, culture, economics, healthcare systems, socio- historical, geography, the media and ecosystem health. For further details of PCCM: 1. Appendix 4 of Core Doc 2. “Patient-Centred Medicine: transforming the clinical method” M Stewart et al, 2003 on reserve in the Health Sciences Library; a useful excerpt from this text is at http://www.uwo.ca/fammed/ian/patcen.htm 3. Patient-Centred Interviewing Parts I to III http://www.ncbi.nlm.nih.gov/pmc/issues/162784/ 4. “Tell me about yourself: The Patient-Centered Interview” F Platt et al, Ann Intern Med. 2001; 134: 1079-85 http://www.annals.org/content/134/11/1079.full.pdf+html

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C. Finding Common Ground “CCG Two – Explanation and Planning” provides many detailed points to assists students in finding Common Ground with patients. PCCM describes finding common ground as “the process through which the patient and doctor reach a mutual understanding and mutual agreement in three key areas: defining the problem; establishing the goals and priorities of management; and identifying the roles to be assumed by both the patient and the doctor.

Example:

John, aged 79, was a creature of habit, who lived alone but enjoyed walking “uptown” several times a week, for his groceries, to go

to the bank, and to have a soda at the legion. He had come in to follow-up after recent discharge from hospital for his first bout of

urosepsis in a year. John was diagnosed 3 years ago with high grade, localized bladder cancer requiring resection and creation of

an ileal pouch that drained urine via an ostomy. John declined the recommended adjuvant chemotherapy and radiation therapy, on

the basis of his prior experiences with his wife and mother, whose battles with cancer and chemo were terrible. John eventually

adjusted to the ostomy, managing bag changes independently but always complained about taking any medication. He disliked the

taste, the required schedules and saw “pills” as a sign of weakness. Following his bladder resection, John developed benign ureteral

strictures on his right side which led to several bouts of urosepsis, requiring hospitalization. He struggled with each admission to

hospital, associating these times with his wife’s and mother’s final days. After much discussion, he agreed to the recommended right

nephrectomy. Following this surgery, John did well until this most recent bout of infection. Infectious disease specialists

recommended daily prophylactic antibiotics to try to prevent recurrent urinary infection. “More pills” was not welcomed by John

but neither was repeated hospital admission. John’s main priority now, in fact, was to reach his 80th birthday, 6 months away. He

described the party already being planned by his eldest of 5 children, a daughter who lived locally and whom he saw sporadically,

describing her as “nosey”. With this priority in mind, John and his physician reviewed his medication list and agreed that a trial off

of his iron and calcium supplements, as well as his proton pump inhibitor (previously prescribed for GERD) was not unreasonable to

reduce his pill burden, making the daily prophylactic antibiotic more palatable. He also agreed to alert his physician at the first

signs of trouble with his remaining kidney, so that oral treatment might be tried, in hopes of avoiding repeat admission. In the past,

John had always held off as long as possible, before coming to the office, essentially denying there was a significant problem, hoping

it would go away on its own. His previous priority was to avoid hospital admissions and doctors. As he came to trust his physician

over time, he was more willing to “come early”, knowing that everything would be done to avoid hospital admission as well as to

support his goal of reaching his 80th birthday.

Key area of Finding Common Ground

Relevant CCG Two Points

1.) Defining the problem -in terms that include both the disease process and patient‟s illness experience

Providing the correct amnt/type of info (1-5)

Aiding accurate recall/understanding (6-11)

Discussing opinion/signif of problem (22-26)

2.) Establishing the goals and priorities of management -putting the patient‟s values at the forefront

Planning: shared decision-making (16-21)

Negotiating mutual plan of action (27-33)

Discussing investigations/procedures (34-36)

3.) Identifying the roles to be assumed by both patient & doctor -as next steps are taken, who will do what, safety nets if things go amiss

Forward planning (37-38)

Ensuring appropriate point of closure (39-40)

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(MDCN 502) Family Medicine Project ASSESSMENT

Presenter Name: _____________________________________ Date: ___________________________________ Project Title: __________________________________________________________________________________

Please assess the student’s performance, providing written comments, including strengths and suggestions for improvement.

A. Description of the Health Challenge The identified health challenge, for either an individual or community, was outlined clearly and an appropriate title was provided.

Poor Borderline Good Very well done Exceptional

1 2 3 4 5 No FIFE Includes basic Nuanced FIFE* FIFE and analysis of prior efforts & outcomes

*FIFE: Patient’s illness experience, including Fears, Ideas, Functional impact, Expectations

B. Exploring the general understanding of the health challenge in the literature The student applied appropriate methodology to select and critically appraise good quality, peer-reviewed family medicine literature, relevant to what is generally known about the identified health challenge.

Poor Borderline Good Very well done Exceptional

1 2 3 4 5 Only non-scientific 2 appropriate references with Clear search strategy, references used basic critical appraisal multiple relevant references, e.g. Wikipedia (max score if no search strategy declared) including original research with overall synthesis

C. Description of the context The relevant individual’s &/or community context of the identified health challenge, is/are carefully considered and clearly outlined.

Poor Borderline Good Very well done Exceptional

1 2 3 4 5 Superficial provides a basic Provides a multidimensional description understanding of individual exploration of individual &/or +/or <3 facets &/or community (@ least 5 facets community, indicating in-depth of context of context explored) analysis of illness experience

Please turn over

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D. Exploring the context in the literature

The student applied appropriate methodology to select and critically appraise good quality literature and/or other resources, to better understand the impact of context on the identified health challenge.

Poor Borderline Good Very well done Exceptional

1 2 3 4 5 Non-scientific 2 appropriate references with Clear search strategy, literature only basic critical appraisal multiple relevant references, e.g. Wikipedia (max score if no search strategy declared) including original research with overall synthesis

E. Translational application of findings: Putting it together, creating options The student applied their findings from literature and other resources, about what is generally understood about the health challenge and the context, proposing options for moving forward on the health challenge. The expected benefit(s) and potential drawback(s) of each option are briefly discussed.

Poor Borderline Good Very well done Exceptional

1 2 3 4 5 List of options 2 well-described > 3 options with clear analysis without connection or of benefits and to context 3 basic options drawbacks relevant to context

F. Common Ground / Next Steps The student (actually or theoretically) involved the patient and/or community representatives to develop a plan that is feasible and acceptable to the patient &/or community in terms of their context (including available time, beliefs, finances etc…)

Poor Borderline Good Very well done Exceptional

1 2 3 4 5 Lack of real Negotiated plan Evidence of clear or planned for next steps negotiation and early negotiation (max score if no follow-up visit implementation or real action taken) of plan underway

Minimum Pass: 18/30 (60%) TOTAL: /30

Comments/suggestions for improvement:

CONTENT DEPTH ORGANIZATION/DELIVERY Assessor name: ____________________________ Assessor Signature: ______________________________ ____ Preceptor ____ Faculty ____ Colleague

Revised 2012 L Nixon, D Keegan; Original version 2010 L Nixon, D Keegan, W Weston