Teaching and Mentoring Patient Centered Care

1. Teaching and Mentoring Patient Centered Care Laurie B. Kontney, PT, DPT, MS Marquette University January 21, 2019 Concordia University School of Health Professions Conference

2. Patient-Centered Care • Patient-centered care is the cornerstone of ethical practice. • The research shows that it is also what separates expert clinicians from practicing clinicians.

3. Interprofessional Practice • Practitioners from various professions learn from and about each other to improve collaboration and the quality of care.  Their interactions are characterized by integration and modification reflecting participants understanding of the core principles and concepts of each contributing discipline and familiarity with the basic language and mindsets of the various disciplines. Clark PG. Journal of Interprofessional Care. 1993; 7(3):219-220.

4. Interprofessional Practice • Consistent demonstration of core values evidenced by professionals working together, aspiring to and wisely applying principles of, altruism, excellence, caring, ethics, respect, communication, accountability to achieve optimal health and wellness in individuals and communities. Stern DT. Measuring Medical Professionalism. Oxford University Press. New York, NY; 2006:19.

5. MODEL OF EXPERT PRACTICEWhat do we know about “expert” physical therapists? Jensen GM, Gwyer J, Shepard KF, Hack LM. Expert Practice in Physical Therapy. PhysTher. 2000; 80(1): 28-43. Resnik L, Jensen GM. Using clinical outcomes to explore the theory of expert practice in physical therapy. PhysTher. 2003;83(12):1090-1106.

6. multidimensional, patient-centered collaborative with patient; reflective Clinical Reasoning Knowledge Philosophy of PT Practice Primary focus centered on function Movement Virtues caring, commitment PHILOSOPHY OF PHYSICAL THERAPY PRACTICE (from APTA Advanced Credentialed CI Program) “Practice begins and ends with the patients.”

7. Philosophy of PT Practice • The PT’s focus is on patient function and expectations rather than a medical diagnosis. • The PT’s focus is on understanding a patient’s story within clinical and experiential knowledge and values rather than by treating based on the medical diagnosis. ( i.e. if this dx I should treat by doing this) • Recognizing the need for consultation and advancing one’s knowledge and skills to meet patient needs.

8. STUDENT NOVICE knowledge philosophy knowledge philosophy clinical reasoning clinical reasoning COMPETENT PRACTITIONER EXPERT CLINICIAN knowledge philosophy philosophy knowledge clinical reasoning clinical reasoning From Shepard, et al., 199911

9. Need to develop Clinical Reasoning/Clinical Decision Making Skills around the Patient – Where are you at?

10. HCI: 67 year old male s/p L THA secondary to osteoarthritis; CVA vs TIA during surgery with R sided weaknessPMH: R BKA, CHF, A-fib, Type 2 DMReferral: PT/OT/SLP s/p THA protocol; WBAT

11. Honestly • First thoughts? • Why were/weren’t you “freaked out”? • What additional information would be helpful? Why? • What questions would you ask? • What would you do? • How is this different from what a student or new grad might think/do? • Did experience to date make a difference?

12. Clinical Decision Making? Clinical Reasoning? Clinical Problem Solving?

13. Clinical Decision Making • The process of formulating a diagnosis; the clinician uses the information gathered from the medical history and physical examination to develop a list of possible causes of the disorder. (Britannica) • The process of coming to a conclusion or making a judgment. (Dictionary of Medicine)

14. Clinical Reasoning • The cognitive process employed by doctors [health care practitioners] in the analysis and interpretation of data that enables them to arrive at a diagnosis and make decisions with regard to treatment and management. (Barrows & Tamblyn, 1980) • The thinking and decision making processes which are integral to clinical practice. (Higgs & Jones, 2000) • The thought processes associated with a clinician’s examination and management of a patient or client. (Jones et al., in Higgs and Jones, 2000)

15. Clinical Problem Solving • The process of recognizing a problem, defining it, identifying alternative plans to resolve the problem, selecting a plan, organizing steps of the plan, and evaluating the outcome. (Dictionary of Medicine) • The process of finding solutions to difficult or complex issues. (Oxford Dictionaries) • The process of working through details of a problem to reach a solution. (Business Dictionary)

16. Is it all “cognitive”, “thinking” and “thought processes”?Hold that thought

17. Activity:Pair up and discuss…

18. Clinical Reasoning • How do you make decisions in novel versus familiar situations? • How do novice students or practitioners make decisions versus expert practitioners? • How do you verbalize or teach what you think? • Do you consider how you will collaborate with other professionals? • How do you model interprofessional practice? • How do you center this learning around the patient?

19. How easy or how challenging was it for you to put words to how you think?

20. ACTIVITY

21. You work in a SNF with a high volume subacute care unit. Prior to leaving for the day the admissions coordinator informs you a patient with a severe CVA is being admitted this evening and will need to be evaluated first thing in the morning.

22. What thoughts did you think of and/or pictures did you visualize in your head as you read this short description?

23. While reviewing the chart you find: • The patient is a 76 year old female. • She sustained a R CVA 5 days ago resulting in dense L hemiplegia and neglect. • She had no significant PMH other than a hysterectomy 15 years ago. • Was Independent with all ADLs and IADLs. • Volunteered 4 x/week in a grade school reading program. • Lived in 2-story bungalow with ½ acre lot.

24. What additional thoughts did you think of and/or pictures did you visualize in your head as you read this information?

25. After interviewing the patient, you have the following information: • Recently widowed. • She has 3 children and 7 grandchildren; all in area; “too busy to be bothered with me”. • Was involved with grandchildren; “won’t be able to spend time with them anymore”. • She enjoyed spending time with family and friends; “I won’t be able to do that anymore”. • Enjoyed quilting and playing cards; “but those days are gone”.

26. What additional thoughts did you think of and/or pictures did you visualize in your head as you read this information?

27. How many hypotheses did you generate?When were your hypotheses generated?What is your next plan of action?How did you determine what you would do next?Did you consider the roles of other members of the interdisciplinary team?

28. Did you consider social and personal aspects of your patient in your decision making?The importance of consulting and working with the interdisciplinary team?

29. Models of Clinical Decision Making/Reasoning • Problem Solving • Hypothetico-Deductive Reasoning Model ‘Hypothesis-Oriented Algorithm for Clinicians II’ (HOAC) • Forward Reasoning • Narrative Reasoning • Interactive Reasoning • Conditional Reasoning

30. PROBLEM SOLVING • Problem presentation and recognition • Problem definition • Problem analysis • Data management • Solution development • Solution implementation • Outcome evaluation May BJ, Newman J. Developing competence in problem solving: A behavioral model. PhysTher. 1980; 60:1140-1145.

31. PROBLEM SOLVING • Problem presentation and recognition – radiating pain R leg -> herniated disc vs musculoskeletal vs neural tension • Problem definition – has pain with sitting, standing, walking; difficulty working, bending, twisting, lifting • Problem analysis – specific tests and measures to rule in and out • Data management – interpret tests and measures to determine course of action/further inquiry and tests and measures • Solution development – POC/interventions • Solution implementation – treatment and reassessment • Outcome evaluation – how progressing/regressing; need to adapt, refer, discharge

32. Hypothetico-Deductive Reasoning Model - HOAC Model • Develop limited set of hypotheses • Use hypotheses to make decisions about questions to ask and tests and measures to perform • Test-collect further data test-decide an intervention-test (linear thought process vs. tacit) • Process oriented • Start general and move to more specific • Typical of inexperienced clinicians (also used by experienced clinicians in novel situations) Edwards I, Jones M, Braunack-Mayer A, Jensen, G. Clinical reasoning strategies in physical therapy. Phys The. 2004; 84(4):312-335. Rothstein JM, Echternach JL, Riddle DL. The hypothesis-oriented algorithm for clinicians II (HOAC II): A guide for patient management. PhysTher. 2003; 83(5):455-470.

33. What are these? • XXX XX XXXX • XX XX XXXX • XXX XXX XXXX

34. FORWARD REASONING • Specific observations and data set lead to a generalization • “If-then” pattern recognition • “Illness scripts” • Used by experienced and expert clinicians - faster and more efficient Edwards I, Jones M, Braunack-Mayer A, Jensen, G. Clinical reasoning strategies in physical therapy. Phys The. 2004; 84(4):312-335.

35. FORWARD REASONING • Specific observations and data set lead to a generalization – left lateral lean in sitting and standing with slight forward flexion of trunk • “If-then” pattern recognition – herniated disc, trying to move disc protrusion away from nerve root • Other examples: if R sided weakness then L CVA or brain injury; if valgus mechanism of injury then MCL involvement; if valgus stress positive at knee then MCL damage; if upper accessory breathing with tingling in R arm then TOS

36. NARRATIVE REASONING Understanding the “person” inside the patient via their story, illness experience, context, beliefs and culture. Validating the importance of these elements by reflecting understanding of them back to the patient. Integrating these elements into the clinical reasoning and decision making process for the patient’s care. Edwards I, Jones M, Braunack-Mayer A, Jensen, G. Clinical reasoning strategies in physical therapy. Phys Ther. 2004; 84(4):312-335.

37. Narrative Reasoning Dialogue • PT: How do you feel your life has been affected by your condition? • Patient: I feel I am not being a good father because I can’t play with my kids after work like I used to. • PT: What I hear you saying is that you feel your back pain is keeping you from playing soccer with your kids, and that is important to you as a father. • Patient: Yes, that is right. • PT: Let’s make sure to prioritize that in our plan for physical therapy; we will work on ways you can build back up to being able to safely play soccer with your kids again. • Patient: That would be great.

38. INTERACTIVE REASONING • Interactions between clinicians and their patients • Working to better understand the patient • Collaboration • Teaching • Ethical practice Edwards I, Jones M, Braunack-Mayer A, Jensen, G. Clinical reasoning strategies in physical therapy. PhysTher. 2004; 84(4):312-335.

39. INTERACTIVE REASONING • Interactions between clinicians and their patients – active listening to what patient is saying with attention to verbal and non-verbal messages • Working to better understand the patient – asking follow up questions and listening to the patient’s story and how illness/injury has impacted them; personal needs/wants • Collaboration – between patient/family/caregiver and therapist to develop a patient centered POC • Teaching – to promote patient/family/caregiver involvement • Ethical practice – best practice and highest quality of care in the interest of the patient (Code of Ethics and Practice Standards/Guidelines)

40. CONDITIONAL REASONING • Reasoning we perform on our own thinking processes • Reflection on the clinical encounter with the patient • Critiquing our reasoning process Mattingly C, Flemming MH. Clinical Reasoning. Philadelphia, PA: FA Davis; 1994.

41. Which of these models did you use in the previous case?

42. ApplicationActivity

43. Your learner (student, new grad, resident, new to your practice setting) readily seeks out and accepts feedback, however, you notice that with each new or existing patient they struggle with applying what was “learned” in your feedback sessions.

44. This decreased ability to transfer knowledge to new and existing patients is pronounced with novel patients and patient’s with co-morbidities.

45. Regardless of their examination findings, evaluation, diagnosis and prognosis and/or current treatment session; they create/follow the same plan of care and subsequent interventions.

46. Additionally, you note that they rarely consider the impact of other members of the interdisciplinary team on the overall quality of patient care unless prompted to do so. Frequently requires prompting to discuss/consult with other team members.

47. Which clinical decision making/reasoning models are problematic?

48. Another important consideration in patient centered care…

49. Informed Consent or Refusal Is Informed Consent/Refusal a legal or ethical imperative?

50. Informed Consent/Refusal • Does the patient have a right to know that they will be working with an assistant, aide, or student? • How do you inform a patient that an assistant, aide, or student will be working with them? • How do you obtain their consent? Document it?