Can an adherence simulation enhance medical student understanding of the challenges patients face in taking medication? Suzanne Minor, MD

Disclosures I have nothing to disclose

Objectives On completion of this session, participants should be able to: Explain the importance of adherence to patient care Describe an experiential, learner-centered activity teaching students about factors affecting patient adherence

Why is adherence important? Medication adherence is integral in helping to control and treat many diseases.1-4 Adherence is a vital component of patient-centered care and contributes to patient success in reaching treatment goals and outcomes.1,3 Specific physician behaviors can improve adherence.4-9

Background MedEdPortal contains modules on teaching adherence using small groups, standardized patients, and lecture, but no first person role-playing simulations. Educators understand that first person educational experiences are learner-centered and thus may help learners achieve better understanding of their role in adherence.

Student Simulation Assigned reading (home grown handout based on lit search, updated annually) First year medical students are assigned to 1 of 6 cases varying in complexity and diagnosis: tobacco cessation, HIV, diabetes, renal failure, CHF. Reflective writing assignment Group presentation

Student Instructions If you have diabetes or nut allergies (the M&M’s were made in plant that may also process nut products) or follow a kosher diet and are thus not able to participate, you are released from ingesting the candy “pills”. Instead of being a patient, you will be a caregiver who needs to remind a family member (in other words, a fellow student) to take their medication.

You came to the clinic today because your lips swelled when you started the medication the doctor gave you last week for your blood pressure. You stopped that medication. Today, the doctor did not have much time for you and saw you quickly. You are very afraid of taking a new medication. The doctor was frustrated and irritated that you were so worried about trying a new medicine, saying in a biting tone that you just had an allergic reaction to the other one, for goodness’ sake! The doctor interrupted you each time you brought up your worries and told you to just stop worrying. During the conversation, the doctor was angled 60 degrees away from you. When the doctor examined your lips, he gave you advice on how to take the new medication, but you were not able to pay attention during the exam because you were focusing on keeping your mouth open. In the end, the doctor told you to take the medication or get ready for a heart attack, crossing his arms and shaking his head. You are already taking a medicine for your diabetes and hypothyroidism. You fill your prescription for the blood pressure and do your best.  

Students are given a bag with all tablets: metformin 1000 mg po bid – blue M&M (14) glyburide 10 mg po daily – orange M&M (7) levothyroxine 125 microgram daily - brown jelly bean – (7) enalapril 10 mg daily – green jelly bean (7) And written instructions: metformin 1000 mg by mouth twice daily glyburide 10 mg by mouth daily levothyroxine 125 microgram by mouth daily enalapril 10 mg by mouth daily

Student Individual Assignment: What were the instructions you were given? How was your adherence? What specific factors affected your adherence? The factors are found in this student handout are categorized under: social/economic, health systems/health care team, condition/disease-related factors, therapy related, patient-related, and doctor related. Don’t just give the category; give the specific factor affecting your adherence. Also, if there was a factor not listed, please include this as well. What was the main take home point for you from this exercise? How will your learning from this exercise affect your behavior as a physician?

Student Simulation: Complete anonymous evaluations In the end of the year OSCE, students are evaluated regarding adherence questions they ask about patient

Assessment of Activity An anonymous survey given to students at the end of the student presentations Comparing OSCE data before and after this activity was implemented with respect to students asking standardized patients about patient adherence

Student Assessment I learned a skill from this activity which will help me to be a better physician. This activity helped me to consider physician behaviors that improve patient adherence.  This activity helped me to consider the relationship between patient autonomy and adherence.  This activity helped me to consider social, cultural, and patient-related factors that affect patient adherence. What did you learn from this activity?  How could this activity be improved?  Questions 1-4 are by Likert Scale: 1= Strongly Disagree 2= Disagree 3= Neutral 4=Agree 5=Strongly Agree

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