What does my UIM attending expect on the Mini-CEX?Round 17/17/13

General Guides The Mini-CEX, or observed history and physical exam, is a

board requirement of the ABIM The attending physician must observe you as you do

portions of the history and physical. Do not ask the attending to “sign off” because you have presented the history or physical findings

Your attending will not make overt corrections to your technique when you are with the patient, but will give you feedback afterward. We do not want to undermine your relationship with the patient

Plan the Mini-CEX, tell the attending, then take the attending in the room to watch – no need to do this twice. Use Chief Complaint as your guide.

General Guides Barbara Bates remains a great reference All of your histories and physicals will be

tailored to the patient’s chronic issues or chief complaints (for the rest of your life!)

Get patients into gowns for anything involving a stethoscope. Nothing causes your UIM attending more angst than watching you try to auscultate anything through clothes!

You need your H&P skills for outpatient Internal Medicine – this is our main procedure

Relative Gain from the History, PE and labs “In 61 patients (76%), the history led to the

final diagnosis. The physical examination led to the diagnosis in 10 patients (12%), and the laboratory investigation led to the diagnosis in 9 patients (11%). The internists' confidence in the correct diagnosis increased from 7.1 on a scale of 1 to 10 after the history to 8.2 after the physical examination and 9.3 after the laboratory investigation.”

West J Med. 1992 February; 156(2): 163–165

Physical Exam remains important "You know, we often spend so much time

with that entity in the computer  — I call it the 'iPatient,' like your iPad and your iPhone. And the real patient in the bed is often left wondering, 'Where is everybody? What are they doing?' I sense that we're spending very little time at the bedside.“

Abraham Verghese, MD Stanford – quoted on NPR

Mini-CEX UIM 2013Item Date Supervisor1. History of a new

complaint    1. Medication

history    1. Chronic pain

history (psych)    1. Focused physical

exam    1. CV exam    1. Lung exam    1. Abdominal exam    1. Musculoskeletal

exam    1. Neurological

exam    1. Pelvic exam

(GYN)    1. Knee exam

(Ortho)    1. Shoulder exam

(Ortho)    1. Hip exam (Ortho)    1. Teach-back    1. Shared decision-

making    

History of a new complaint Remember “COLDERR AS” for pain:

“O” Onset “L” Location “D” Duration “C” Character/Quality “S” Severity “R” Radiation “E” Exacerbating/”R” Relieving “A” Associated symptoms

Medication History Physicians should be doing “Medication Reconciliation” Medication Reconciliation

Create the most accurate list possible of all medications a patient is taking Drug Name Dosage Frequency Route

Compare that list against the physician’s admission, transfer, and/or discharge orders

GOAL: provide correct medications to patient at all transition points

(Amy Thompson, PharmD)

Medication History Emphasis at Hospital Discharge Comparing what patient is taking at home to

the Epic list and hospital discharge list – identifying high risk medications

Using outside resources Call pharmacies/family Home Health orders

Creating accurate list in Epic Using Teach-Back to clarify patient instructions

Chronic Pain History History of the pain including diagnostic studies All medical records obtained including DHEC report Previous treatments and response/adverse effects – focus on function Psychosocial factors and family history – include compensation/legal

factors UDS Goals of therapy - functional Assessment of risks for opioid abuse (DIRE)

Personal or family history of drug abuse(tobacco use) Psychological factors: personality disorder, affective disorder, etc. Reliability: medication misuse, missed appointments Social support Efficacy: functional

Documentation in the Problem List

Focused Physical Exam Can you limit the physical to the chief

complaint and/or chronic medical conditions?

HTN – CV exam, measure BP manually Cardiac history – CV exam, lungs Headache – neuro exam critical Etc.

Teach-Back

[Elisha Brownfield]stolen from:

A program created by the Minnesota Health Literacy Partnership

The problem with communication is the illusion that it has occurred.

>-- George Bernard Shaw

Teach-Back . . . ● Asking patients to repeat in their own words what they

need to know or do, in a non-shaming way.

● NOT a test of the patient, but of how well you explained a concept.

● A chance to check for understanding and, if necessary, re-teach the information.

Teach-Back . . . Why?Teach-Back is supported by research!

● “Asking that patients recall and restate what they have been told” is one of the 11 top patient safety practices based on the strength of scientific evidence.”

AHRQ, 2001 Report, Making Health Care Safer

● “Physicians’ application of interactive communication to assess recall or comprehension was associated with better glycemic control for diabetic patients.”

Schillinger, Arch Intern Med/Vo640 l 163, Jan 13, 2003, “Closing the Loop”

Teach-Back . . . How?Ask patients to demonstrate

understanding “What will you tell your spouse about your condition?” “I want to be sure I explained everything clearly, so can you

please explain it back to me so I can be sure I did.” “Show me what you would do.”

Chunk and checkSummarize and check for understanding throughout, don’t wait until the end.

Do NOT ask . . . “Do you understand?”

Additional Points. . . ● Slow down.● Use a caring tone of voice and attitude.● Use plain language.● Break it down into short statements.● Focus on the 2 or 3 most important concepts.

Shared decision-making What is shared decision making? Shared decision making is an approach

where clinicians and patients make decisions together using the best available evidence. (Elwyn et al, BMJ, 2010

Shared Decision-making for: undergo a screening or diagnostic test undergo a medical or surgical procedure participate in a self-management

education program or psychological intervention

take medication attempt a lifestyle change. www.kingsfund.org.uk

Elements from the Clinician developing empathy and trust negotiated agenda-setting and prioritizing information sharing re-attribution (if appropriate) communicating and managing risk supporting deliberation summarizing and making the decision documenting the decision

How do I do that? Negotiated agenda setting/prioritizing

‘What do you want to talk about in our time together today?’

‘What questions do you have?’ What concerns do you have?’ ‘What is it that I need to know so that I

can help you reach the best decision?’ ‘There are other things that I’d like to

discuss – is that OK?’

How do I do that? Information sharing

‘What do you understand about your condition?’ ‘What do you understand about what is

happening in your body when you get your symptoms?’

‘What have you been told about your condition?’ ‘What have you been told is happening in your

body when you get your symptoms?’ ‘What concerns or worries do you have about

your condition?’

How do I do that? Re-attribution

‘Many people who have angina think like that. The evidence is that angina isn’t actually a heart attack. Now I have shared that thought with you, what does that mean for you?’