1. Georgetown University School of Medicine A Clinical Decision Support and Shared Decision-Making OSCE for Third-Year Medical Students STFM MSE 2012 A Clinical Decision Support and Shared Decision-Making OSCE for Third-Year Medical Students STFM MSE 2012 Jeff Weinfeld, MD Steven Schwartz, MD Georgetown University School of Medicine

2. Georgetown University School of Medicine Educational Goals and Objectives By the end of the session the participant will:  Understand the motivating features behind the OSCE including clinical decision support and shared decision making  Describe our Institution’s medical school curricula that supports the OSCE  Discuss the strengths and weaknesses of teaching clinical decision support and shared decision-making in various curricular formats  Describe the OSCE implemented and its evaluation  Reflect on existing curriculum and consider how to add clinical decision support or shared decision- making to an existing curriculum or OSCE

3. Georgetown University School of Medicine What does the well-prepared, tech savvy student look like? What can she do? What does the well-prepared, tech savvy student look like? What can she do?

4. Georgetown University School of Medicine A picture

5. Georgetown University School of Medicine CDS/SDM OSCE Goals  Incorporate a live standardized patient  Apply EBM  Use handheld (now iOS) with patient to make a clinical decision  Use shared decision making with the SP

6. Georgetown University School of Medicine Evidence-Based Medicine “The conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence- based medicine requires integration of individual clinical expertise and patient preferences with the best available external clinical evidence from systematic research.” -Gordon Guyatt, MD. Users' guides to the medical literature: A manual for evidence-based clinical practice. Guyatt G. Rennie D eds. 2002, p 674.

7. Georgetown University School of Medicine Point-of Care tools  A way to do EBM  Handheld curriculum since 2002  Requirement since 2005  Vehicle for better decision-making  Some evidence for better care with handhelds (Berner Jamia 2006, Prgomet JAMIA 2009)

8. Georgetown University School of Medicine Clinical Decision Support (CDS)  Definition: software that helps doctors make clinical decisions about an individual patient using computerized knowledge  Improve physician performance (Garg JAMA 2005;293:1223)  Examples  Diagnosis or management aids  Reminders “Mrs. Jones is now 50: please remember to order a mammogram”  Alerts: “the patient is allergic to penicillin”  Guideline use  Handheld calculators

9. Georgetown University School of Medicine Electronic Health Record Use  Is now up to 57% of physicians  52% of physicians plan to apply for meaningful use incentives  Hsiao, NCHS Data Brief 2011

10. Georgetown University School of Medicine Shared Decision Making  Decision making where the physician and patient are involved, share information, take steps to build a consensus about the preferred treatment, and both parties agree about the chosen treatment.  Charles 1997

11. Georgetown University School of Medicine CDS OSCE  Summative OSCE  Given at end of M3 year with other OSCEs  Emphasis on  Management  Use of handheld decision rule  Shared decision making

12. Georgetown University School of Medicine

13. Georgetown University School of Medicine Georgetown Curriculuar Overview  M1/M2 Science Modules and Longitudinal Doctoring Curriculum  Formative OSCEs at end of M1 M2  4 wk FM clerkship with shared decision making formative OSCE  Summative OSCE after M3

14. Georgetown University School of Medicine Curricular Touchpoints - Detail Commuication Skills o Doctoring Curriculum (M1) EHR/Decision Support o Lectures on EHR and Quality (M1) EBM Courses o M1 - Basics o M2 - Evaluation of articles/application Handheld Curriculum - starts M2 o Pharm, Lab Med, EBM (M2), Clinical Skills Primer (M2), Clin Pharm (M4) o Clinical Skills Day (M3) ePrescribing o Hands-on o Used in cases throughtout M2

15. Georgetown University School of Medicine Curricular Touchpoints - FM Clerkship Point-of-Care Question Answering Workshop (web/handheld POC resources) Shared decision making/motivational interviewing workshop End-of clerkship Formative OSCE o Communicate with a SP surrounding a simulated computer o eprescribing o Receive feedback based on EHR best communication practices (Morrow 2009)

16. Georgetown University School of Medicine Discussion What are you teaching in clinical decision support and shared decision making? How are you teaching AND evaluating it? What are the strengths and weaknesses of your format?

17. Georgetown University School of Medicine First "EBM" OSCE  M3, summative  Rationale: EBM/Handheld Skills  Paper case without SP  MEDLINE Searching  Handheld  Dose calculation/renal adjustment  Drug interaction

18. Georgetown University School of Medicine OSCE Evolution

19. Georgetown University School of Medicine Typical OSCEs  Focus on history and physical - data gathering  Diagnostic focus  Plan paternalistically delivered  Limited discussion with patient

20. Georgetown University School of Medicine Case Elements  Straightforward history and physical  Diagnostic information readily provided  Limited diagnostic uncertainty  Accepted decision rule  Case elements require shared decision- making  Decision rule supports one action  Psychosocial issues cause resistance

21. Georgetown University School of Medicine Grading  SP Observation  History Checklist - Yes/No  Communication Checklist – standardized Likert 0-5 scale  Post-encounter questionnaire

22. Georgetown University School of Medicine Grading of Key Elements Evaluation Method Did They: SP Observation Post-encounter questionnaire Convey risk to patient?X Use the handheld CDS tool?X Do shared decision making?X Make Dx?X Calculate the correct risk score?X Create a planX

23. Georgetown University School of Medicine SP Grading - History Checklist 1.Elicited resistance 2.Planned follow up 3.(SP Prompt - not graded) 4.Conveyed risk 5.Explored resistance and solutions 6.Shared information from handheld visually (triangle of computer, patient, physician)

24. Georgetown University School of Medicine SP Grading Communication Checklist 7.Appears professionally competent 8.Gathered information effectively 9.Active listening 10. Established professional rapport 11. Explored patient perspective 12. Addressed feelings 13. Met needs including negotiating a mutually agreeable plan 14. Overall level of patient satisfaction

25. Georgetown University School of Medicine Post-Encounter Write-up  Give decision-support score  Give associated clinical risk parameter (eg mortality risk)  Working diagnosis and rationale  Management

26. Georgetown University School of Medicine Development - tradeoffs  How many questions evaluated by SP vs by post-encounter  More complicated Dx vs less time for shared decision making

27. Georgetown University School of Medicine Challenges  Proscribed format  Multiple elements for student  Different focus for student  Higher-level skills  Adds variability  More innovative = More difficult ?  Technical issues

28. Georgetown University School of Medicine Thank you Acknowledgement: This work was supported by The Health Resources and Services Administration (HRSA), (D56HP00085-07-00) 2009-2012