Structured Group Reflection and Improvisation: Developing skills for the medical home in a variety of cultural settings Daisuke Yamashita MD 1, Kenichi Yokobayashi MD 2, Morito Kise MD 3, Yasuki Fujinuma, MD 2, Randall Longenecker, MD 4 1. OHSU Family Medicine 2. HCA-JCCU Family Medicine Residency Program Tokyo 3. Kawasaki Municipal Tama Hospital Family Medicine Residency 4. The Ohio State University Rural Program HCA-JCCU Family Medicine Residency Program Tokyo Kawasaki Municipal Tama Hospital Family Medicine Residency OHSU Family Medicine The Ohio State University Rural Program Bring a case & a question Implement in practice Clarify the question Refine the question Inter-textual reflection Take away a pearl Background: The Patient-Centered Medical home (PCMH) requires special competence in addressing the following: 1.Uncertainty – unique and surprising clinical cases are not strictly biomedical. 2.Complexity – multiple relationships with multiple layers of sociopsychological meaning challenge even the experts among us. Training in uncertainty and complex bio-socio- psychological problems is essential to implementing a PCMH. “Clinical Jazz” A semi structured small group process designed to promote reflection and develop skills working in a complex, relationship-rich environment. 1. Pick an emotionally moving case, prompting surprise, sadness or confusion. (self reflection) 2. Draw a Genogram (relationship centered) 3. Open discussion with group. Everybody participate! EBM and experiences are woven in the discussion. 4. Conclude with a “clinical pearl” 5. Reflect on the case and proceed to practice Diffusion of an innovation 1998 Shaughnessy AF, Slawson DC, Becker L. Clinical jazz: Harmonizing clinical experience and evidence-based medicine. J Fam Pract 1998;47: Birth of “Clinical Jazz” as introduced by Dr. Longenecker at Mad River Family Practice in Ohio April Dr. Fujinuma found Dr. Longenecker’s presentation on internet May Dr. Yamashita met Dr. Longenecker at an STFM conference in San Francisco 2006 April “Clinical Jazz” was adapted to the residency in Tokyo (Dr. Fujinuma and Dr. Yokobayashi) 2006 April “Clinical Jazz” was adapted to the residency in Kawasaki (Dr. Kise) 2006 July Dr. Yamashita moved to OHSU, Portland Oregon for residency March Dr. Fujinuma and Dr. Yokobayashi received “Best Teaching Pearl Award” at 15th Japan Society of General Medicine annual conference July “Clinical Jazz” was adapted to OHSU Family Medicine South Waterfront clinic (Dr. Yamashita) Dr. Yasuki Fujinuma, Dr. Kenichi Yokobayashi Setting: Based in Tokyo, Japan. Total of 11 residents with 10 faculties. Network of 6 urban clinics. Emphasis on home care and geriatric care. Name: "Clinical Jazz" When: Once a month at the residency conference. Time: 30 minutes x 2 cases Who: Residents and Faculty Dr. Daisuke Yamashita OHSU Family Medicine South Waterfront Clinic Based in Portland Oregon. In large academic medical center. Part of OHSU FM residency. Total of 12 residents in this clinic. Urban setting and patients with diverse ethic background. Name: “Difficult Case Conference” When: Once a month at the clinic Time: 30 minutes x 2 cases Who: Residents, faculties and a clinical psychologist Dr. Morito Kise Based in Kawasaki, Japan. City next to Tokyo. The clinic is part of 300-bed community hospital. Total of 7 residents. Emphasis on inpatient, pediatrics and emergency care. Title: “Clinical Jazz” When: twice a month Time: 60 min, single case Who: Residents and Faculties. Challenges: 1. Requires experienced facilitator to lead discussion. -Discussion may become scattered and unfocused. -A facilitator can avoid this by keeping the group focused on the original question. 2. Difficulty formulating clinical pearls, i.e. taking the “action turn” -Requires everyone’s participation to come up with pearls; forces improvisation -Improves over time as group becomes used to this process. 3. Difficulty finding evidence in literature. Discussion: “Clinical Jazz” was successfully implemented among four different residencies in different clinical and cultural settings. "Clinical Jazz" promotes relationship centered medicine, reflective practice and balancing evidence and experience in different cultural contexts and provides a safe “educational home” for difficult cases This suggests that "Clinical Jazz“ may be useful in a patient centered medical home, dealing with cases of great complexity and uncertainty. Next steps: -Share "Clinical Pearls" among residencies. -Develop evaluation tools to measure the effectiveness of "Clinical Jazz" in promoting reflective practice. -Evaluate the impact upon patient care -Incorporate other clinical staff in the setting of a patient centered medical home, further promoting team-based care. Dr. Randall Longenecker Setting: Mad River Family Practice, West Liberty, Ohio. A “2-2-2” integrated rural training track residency Name: “Clinical Jazz” and “Faculty Jam” When: Weekly, on Thursdays Time: 75 minutes, single case Who: Residents, Faculty (including residency coordinator and clinical psycologist), and visiting students or other guests (“Faculty Jam” is for faculty only) Contacts: Daisuke Yamashita Kenichi Yokobayashi M.D.