Teaching and Evaluating the Follow-up Visit: A 2-staged Patient Simulation Carol P. Motley MD Ehab Molokhia MD University of South Alabama College of Medicine Mobile, AL

Chronic Care - The “follow-up” visit Aging of the US Population Ecology of healthcare Every month, out of 1000 people < 8 admitted to a hospital and < 1 to an academic health center Continuum of care Inpatient/outpatient Complex patients with multiple chronic problems Time limitations

Efforts to Define Chronic Care TOPIC Curriculum (Baylor COM, 2003) – Task Oriented Processes In Care – Identifies tasks for the “Chronic Illness Visit” Assess the patient’s expectations and concerns Assess severity and control of the condition Evaluate adherence to and side-effects from treatment Scan for target-organ damage Review status of co-morbid conditions SNOCAMP (Larimore, 1995) – Suggested medical record format – “Invoice for Chronic Care” – Additions to SOAP note N-Nature of presenting problem C-Counseling/coordination of care M-Medical Decision-making

Chronic Care Model (Wagner, 2001) – Paradigm shift: Team approach – Recognition of importance of psychosocial and community components of care with utilization of ancillary health providers and health resources – MD role as Team Leader Provider of care

More Ecology of Healthcare:

One student’s comment “But here’s the thing: most of that stuff is about as exciting as watching paint dry. Checking the lipids and the A1c, making sure the pt gets an eye exam and a tetanus shot–this kind of thing, while important for population health, is simply brain rot–and relatively underpaid brain rot at that. And oh the paperwork.” unknown author

Our Observations at USA COM Our students see the office visit as an isolated entity rather than one point on a continuum of care Most of our students view the MD as the focus of care Many of our students are poorly prepared to address behavioral change in patients with only traditional H & P training Some students have difficulty prioritizing issues to address when presented with multiple complex chronic diseases Preventive care is seen as an “add-on” component of care

Our Method Traditional Medical School Model 6 week Family Medicine Clerkship Orientation – Importance of Primary Care in the healthcare system – Preventive Care – Motivational Interviewing Day 1/Phase I interview: The student is videotaped interviewing a new patient with a complex history: educational only – SOAP note – Patient evaluation – Faculty review the video and the interview is made available to the student on the web 5 weeks with community faculty 6 weeks/Phase II Interview The follow-up visit--The student sees the same patient – Summative Evaluation

– Knowledge of disease processes – Ability to integrate multiple interacting disease process and prioritize management issues – Utilization of evidence based interventions over time Guideline driven care – Understanding comprehensive healthcare which incorporates prevention as a basic component of care – Motivational skills for addressing behavioral change – Teaching patient self-management and encouraging self-efficacy Skills of the physician in chronic care:

Skills Evaluation Manage Chronic Disease (s) Motivate Behavioral Change Provide Patient Education Encourage Patient Self Management Recommend Preventive Care Arrange ongoing follow-up care

“Healthcare requires more than physicians.” L. Michener 2001 The future primary care physician is not only as the subject matter expert, but the orchestral conductor of the patient’s healthcare over a lifetime.

References J Rogers, J Corby, Joyce Dains, et al. “Task-oriented Processes in Care (TOPIC): A Proven Model for Teaching Ambulatory Care” Fam Med 2003:35(5): W L Larimore, EV Jordan. “SOAP to SNOCAMP: improving the medical record format-subjective, objective, assessment and plan of treatment with nature of the presenting complaint, counseling and medical decision making” J Fam Practice 1995 E H Wagner, BT Austin, C Davis, et al, “Improving Chronic Illness Care: Translating Evidence into Action” Health Affairs. 2001