Family - Project Requirements

The purpose of this project is to organize and then to present a whole-person, patient-centred approach to an individual patient or several thematically related patients who present(s) during your time with your preceptor. You are expected to include your knowledge of the patient and your preceptor’s approach and should integrate current literature on the chosen problem. Guidelines:

• A whole-person approach: should include the effect of the illness on the patient and family using the patient-centred clinical method. Awareness of the cost implications of the illness (including investigations and medications) should also be addressed.
• It is expected that only generic names will be used for drugs.
• A discussion of at least two of the Principles of Family Medicine and how the patient you have chosen illustrates those principles should be included. (The four principles of family medicine are attached.)

The recommended texts for this project are:

• Stewart M et al.: Patient-Centred Medicine – Transforming the Clinical Method, 2nd edition, Radcliffe Medical Press, 2003.
• McWhinney IR, Freeman, T: A Textbook of Family Medicine, 3rd edition. NewYork: Oxford University Press, 2009.

YOUR CLINICAL PROJECT WILL BE EVALUATED BASED ON THE FOLLOWING CRITERIA:

1. Integration of your personal knowledge base with your preceptors’ approach and with current evidence-based literature.
2. Appropriate reference to the Patient-Centred Clinical Method and a description of the effects of the illness on the patient and the patient’s family.
3. Cost awareness of both investigations and medications.
4. Demonstration of understanding of at least two Principles of Family Medicine.
5. Presentation Skills.

This option involves doing a project that looks at Screening in Family Practice. The recommended text for this project is the Canadian Guide to Preventive Health Care. This text presents the work of the Canadian Task Force on Preventive Health Care which is available online at http://www.ctfphc.org/ Another excellent resource is the U.S. Preventive Services Taskforce at http://www.ahrq.gov/clinic/prevenix.htm#uspstf.

In this project, you are asked to address one area of screening in your preceptor's practice. Examples include Mammography, Pap Smear Testing, Alcohol Risk Assessment, Smoking Cessation, Screening for Hypertension, Screening for Sexually Transmitted Diseases, etc. You are asked to identify what the current recommendations are for the screening procedure you have chosen and to identify the facilitators and barriers in your current practice for implementing these screening guidelines. You may look at recall systems, patient education, physician variables and office organization, and how these parameters affect the application of screening recommendations in family practice.

You must review 10 - 20 charts to assess how successfully the screening intervention you have chosen has been applied in the practice and should include the results of this 'mini audit' in your report. You should also comment on the evidence on which the specific screening recommendations, in the area that you have chosen, are based. What resources exist locally to help family physicians keep up-to-date with these recommendations and how do practicing physicians change their behaviour based on current screening recommendations?

We are awash in guidelines and it is often difficult to know how to choose the "best” guideline on a particular topic. This option allows you to research a clinical practice guideline on a particular area of family practice that interests you and is applicable to the practice that you have been assigned to for your rotation. To complete this option, you must obtain a copy of the clinical practice guidelines in your area of special interest. Examples are: Asthma, Diabetes, Ischemic Heart Disease, Atrial Fibrillation, Hypertension, Congestive Heart Failure, Hyperlipidemia, COPD, Menopause, and Osteoporosis. You must apply critical appraisal skills to the clinical practice guidelines that you selected. This would include commenting on the following:

1. Are the recommendations in the guidelines valid?

• Did its developers carry out a comprehensive, reproducible literature review within the past 12 months?
• Is each of its recommendations both tagged by the level of evidence upon which it is based and linked to a specific citation?

2. The "Killer Bs”

• Is the Burden of Illness (frequency in our community, or our patient’s per-test probability or expected event rate [PEER]) too low to warrant implementation?
• Are the Beliefs of individual patients or communities about the value of the interventions or their consequences incompatible with the guideline?
• Would the opportunity cost of implementing this guideline constitute a bad Bargain in the use of our energy or our community’s resources?
• Are the Barriers (geographic, organizational, traditional, authoritarian, legal, or behavioural) so high that it is not worth trying to overcome them?

Using these guidelines, you are to critically appraise the appropriateness of the guidelines that you have chosen and to discuss their usefulness in your preceptor's practice. You are required to examine at least 5-10 charts of patients to assess how the guidelines have been applied in your preceptor's practice and to include this assessment in your report. In particular, you may want to comment on the specific barriers that exist in applying clinical practice guidelines to family practice and how these barriers can be addressed.

There are a large number of good guideline sites. It is worth knowing about the following:

• Three superb resources are available from the Outreach website of the Allyn and Betty Taylor Library at http://www.lib.uwo.ca/taylor/outreach
  • InfoPOEMS
  • Clinical Evidence
  • UptoDate is available at Western and in SWOMEN hospitals and some clinics.
• The Canadian Medical Association Clinical Practice Guidelines Infobase –http://mdm.ca/cpgsnew/cpgs/index.asp
• BMJ Updates http://bmjupdates.mcmaster.ca/index.asp
• The Agency for Health Care Research and Quality in the U.S. at http://www.ahcpr.gov/
• The website for the Canadian Library of Family Medicine at http://www.cfpc.ca/English/cfpc/clfm/main/ provides a list of other guideline sites.
• The Ontario Medical Association and the Ministry of Health and Long Term Care have collaborated in developing "Guidelines on guidelines”. See http://www.gacguidelines.ca/ for a review of guidelines on over 75 common topics in primary care (new topics are added regularly). 10 or more guidelines were reviewed for each topic. The guidelines are given a rating of 1-4 apples based on robust criteria.
• The TRIP database searches several high quality sites all at once. See http://www.tripdatabase.com/.

In this project, the student will define a question that arose from seeing patients in the office and will seek out information to produce a trustworthy answer. The steps in the process include the following:

• Define a "well-formed” question based on a patient (or patients) seen in the practice. A "well-formed” question is one that is important for patient care and which can be researched and answered in a reasonable period of time. For good examples of "well-formed” questions, see the Centre for Evidence-Based Medicine at http://www.cebm.net/focus_quest.asp.
• Seek out an answer by one or more means – asking one or more experts, reviewing textbooks, reviewing course notes, reviewing journal articles etc. One of the best, up to date, references is Evans M (Editor): Mosby’s Family Practice Sourcebook – An Evidence-Based Approach to Care 4th edition. Toronto: Elsevier Mosby, 2006.
• One of the best references on drugs is the Medical Letter – all students should become familiar with this concise and authoritative resource available from the Outreach website of the Allyn and Betty Taylor Library at http://www.lib.uwo.ca/taylor/outreach/.
• Students need to be skilled in finding good journal articles quickly using Medline (using either OVID or PubMED which are both available from the Outreach library website). They should also be familiar with a variety of sources of information that has already been appraised e.g. Cochrane Database, Best Evidence, and Clinical Evidence. See Appendix II for more details.

The presentation should include:

• How and why you came up with the question – a description of the original clinical situation which generated the question.
• How you found what you found.
• The validity and applicability of what you found – critical appraisal of the information.
• How what you found might influence the management of the patient or other patients with similar problems.

An excellent text that describes this entire process is Straus SE, Richardson WS, Glasziou P, Haynes RB: Evidence-Based Medicine – How to Practice and Teach EBM. 3rd Edition. London:Churchill Livingstone, 2005. See also Stewart A: Creating your own Internet library. CMAJ 1999;161(9):1155-60. http://www.cmaj.ca/cgi/content/full/161/9/1155

Discrimination is unequal treatment that operates to the detriment of any person on the grounds of race, color, religion, sex, national origin, disabling condition or sexual orientation. Such discrimination is culturally determined and may be invisible to the dominant groups in a society. Physicians are in positions of power and, as such, may unknowingly participate in behaviour that discriminates against certain groups in society. But, because of their power, physicians have the potential to correct some of these inequities. The first step is self-awareness.

It is important to realize that gender issues are not just related to genetics (XX vs. XY genotype), but also to phenotype (somatic gender based on physical appearance and secondary sexual characteristics), psychological gender (based on self-perception and behaviour), and social gender (based on cultural categories)[2].

Examples of Sex and Gender Issues in Medicine:

• How our socialization as men or women affects our behaviour including help-seeking and caregiving e.g. although there has been some change in the roles of men and women in Western culture, women still provide the largest share of homemaking and child care even when they have full time jobs outside the home.
• Single parenthood is also much commoner in women than men, is often associated with poverty and poses additional burdens on women
• The special illness experiences of women i.e. ways in which the illness experience (especially FIFE[3]) differs between men and women
• Differences in rates of presentation for illness between men and women e.g. mental illness (women are much more likely to seek help for mental illness than men)
• Differences in rates of treatment for illness e.g. lower rates of investigation and management of chest pain in women; much higher rate of prescribing of psychotropics (women receive twice as many psychotropics as men)
• Differences in rates of poverty and unemployment between men and women and the impact on their health and health care.
• Sexual discrimination
• Harassment
• Violence against women including screening for violence
• How issues related to reproduction affect men and women e.g. post partum fatigue and depression, abortion, contraception, and infertility.
• Diseases that are exclusive to women or are much commoner in women than in men e.g. cancer of the uterus, ovaries and breast, endometriosis, eating disorders, fibromyalgia, menstrual disorders, osteoporosis
• Impact of life cycle issues e.g. menarche, menopause and our tendency to medicalize these natural processes
• Impact on guidelines of under representation of women in clinical research

Examples of Equity Issues in Medicine:

• Consideration of how patients from visible minorities, aboriginal peoples (First Nations, Métis and Inuit), gay and lesbian persons, and those with disabilities may be disadvantaged
• Understanding of social determinants of health e.g. income disparity is a major influence on health status. See http://depts.washington.edu/eqhlth/ for more information.
• Variations in risk and disease incidence related to minority groups and socio-economic status e.g. "…people’s health care needs usually vary inversely with their power and privilege within society.”[4]
• How illness behaviour varies among different groups e.g. risk taking behaviour, use of health care resources, preventative actions
• The influence of culture on health care e.g. language barriers, cultural stereotyping and discrimination
• Accessibility issues for patients with disabilities e.g. is the practice easily accessible to patients in wheelchairs or those who are blind or aphasic? How accessible is care for patients who must work all day?
• Consideration of how the conventional medical model and the organization of health care services may perpetuate the oppression of disadvantaged groups

This project involves selecting a topic related to at least one gender or equity issue. This could be a case example illustrating how an equity or gender issue was central to effective care of a patient, a practice policy designed to minimize discrimination or bias, or an essay outlining an approach to improving care related to one or more gender or equity issues e.g. how physicians could be more sensitive to these important issues and how the approaches to care could be modified to improve access and quality to disadvantaged groups or individuals. Consider how the patient-centred clinical method can contribute to improved care. Alternatively, the project could focus on a condition that is unique to women or has special features in women and describes how an understanding of women’s issues is important for good care.

For more information see http://www.genderandhealth.ca/index.html.

Topic Suggestions

Describe how one of the following practice management issues positively and/or negatively impacts on office management, patient satisfaction and the quality of patient care. Specifically address how each of the areas listed can affect the physician's job satisfaction and lifestyle, (such as leisure time, family commitments, community involvement, holidays). Use your preceptor’s practice as the basis for your project; giving examples/details where appropriate. How do these issues relate to your practice plans in the future?

Practice Space and Layout

• Patient traffic flow
• Reception/waiting room space
• Work area
• Exam room layout
• Paper flow/filing
• Storage
• Physician private office space/resources
• Equipment access

Office Computer System

• Hardware
• Software
• Scheduling capabilities and ease of use
• Billing
• Email and Internet access
• CME
• Other

Record/Filing System

• Patient files – flow and circulation
• Problem lists
• Medication lists
• Progress notes – SOAP (Subjective, Objective, Assessment, Plan or SOAPE (the extra E is for patient Education) or SOAPPP (the extra PP is for Patient Participation)
• Ease of access – for physicians, staff, etc.
• Storage
• Other resources in practice – library, patient information resources
• Other

Overhead Expenses/Finances

• Total overhead costs including insurance (CMPA/Disability/Life/Office Overhead) Patient volume/practice revenues
• Income tax
• Loan management
• Cost of holidays/CME
• Resources to physicians (bank/MD Management/OMA insurance)
• Fee for service, salaried positions versus other alternative payment plans
• Other

Practice Type and Location

• How do physicians decide where to practice?
• Number of family doctors locally.
• An over-or under-served area.
• On-call arrangement.
• Coverage for holidays.
• CME "time away" from practice.
• Local support for physicians, hospital, home care or other community agencies.
• Opportunities for maternity leave.
• Other

Time Management

• Patient scheduling – office/hospital/house calls/nursing home/OB/OR
• Personal errands, child care/banking, etc.
• Staff responsibilities and delegated tasks
• Telephone - use and abuse
• Paperwork - insurance forms/letters to lawyers/consults/references
• CME
• Committee work/meetings
• Charting
• Use of a personal calendar, Day Timer system, etc.
• Other

Supporting materials on the above are available upon request by contacting MD Management at 1-800-361-9151

This project looks at the outreach function of the family physician and reflects the "advocate” role described by the EFPO (Educating Future Physicians for Ontario) Project. It also relates to two of the four principles of Family Medicine: "The Family Physician is community oriented” and "The Family Physician is a resource to a defined practice population”.

The steps involved in this project include:

• Identify a community need in your preceptor’s practice
• Search the literature for approaches used by others
• Describe a potential community intervention
• List barriers and facilitators

One example of a community project arose from a resident seeing a patient with a severe sinusitis requiring hospitalization secondary to a dental abscess. The dental problem went untreated because of the family’s poor financial situation and lack of awareness of low cost dental care services in the community. The resident contacted dentists in the area and created a brochure outlining how to access low cost dental care and placed the brochures in the offices of local family physicians and emergency departments. A student report would not require actually carrying out the project but should include:

• A description of the situation which stimulated the idea for a community project
• A review of the literature in the area of the need identified
• A description of the community-based intervention
• A description of the barriers and facilitators to implementation and how these could be addressed

Appendix I

The Four Principles of Family Medicine:

The four principles of Family Medicine guide all educational activities of the College of Family Physicians of Canada – including the certification exam. They describe – in brief – what effective family doctors do.

The patient-physician relationship is central to the role of the family physician.

Family physicians are willing to become involved in the full range of problems which their patient brings to them, not just their biomedical problems. They have a deep knowledge of the human condition, especially the nature of suffering and the responses of patients to sickness.

They are aware of their personal assets and limitations and recognise when their own personal issues interfere with effective care.

Family physicians respect the primacy of the person. The relationship has the qualities of a covenant – a promise, by physicians, to be faithful to their commitment to the wellbeing of the patient, whether or not the patient is able to follow through on their commitments. Physicians are cognizant of the power imbalance between doctors and patients and the potential for abuse of this power.

The family physician is a skilled clinician.

Family physicians demonstrate mastery of the clinical method – they integrate a sensitive, skilful search for disease with an understanding of their patient’ experience of illness – particularly their feelings, ideas, the impact of the illness on their daily function, and their expectations of the physician.

Family physicians utilise their understanding of human development, the family system and other social systems to develop a comprehensive approach to the management of disease and illness in patients and their families.

Family physicians are also adept at working with patients to reach common ground regarding the definition of the problem, goals of treatment and roles of doctor and patient in management. They are skilled at providing information to patients in a manner which respects their autonomy and which empowers them to "take charge” of their own health care and to make decisions that are in their best interests.

They have an expert knowledge of the common problems of patients in the community and of less common, but life-threatening and treatable emergencies in patients in all age groups.

They are skilled at critically reviewing the medical literature and have effective strategies for remaining up-to-date – their approach to health care is based on the best scientific evidence available.

Family medicine is a community-based discipline.

Family practice is based in the neighbourhood rather than the institution. As a small-scale organisation, which is part of the community it serves, family medicine is able to respond to the real needs of the people and to adapt quickly to changing circumstances. Family doctors are able to see patients wherever they are – in their homes, in the hospital or in the doctor’s office.

Family doctors, as physicians of first contact, see undifferentiated disease in its earliest stages, and many self-limited disorders. In addition, they see many patients with chronic disease, emotional problems, acute life-threatening disorders and complex problems involving disruption at many levels of the system – molecular, organ system, personal, familial and community. They are skilled at dealing with uncertainty and ambiguity. Family doctors are also physicians of last contact, involved in palliative care of patients with terminal illness.

The family physician is a resource to a defined practice population.

Family physicians define their practice as a "population at risk” – in other words, the physician is able to look at the practice population as a whole and use population-based strategies to improve or protect the health of his or her patients as a group.

Family physicians develop guidelines for personal preventive services based on the best evidence available. They are skilled at presenting the pros and cons to patients in a clear manner that facilitates them making informed decisions about health promotion and preventive care.

Family doctors have practice organisational skills to intervene at a population level – record-keeping methods, chart audits, outreach techniques, recall systems and office management.

Family physicians see themselves as a part of a community network of health care providers and are skilled at collaborating as team members or team leaders. They use referral to specialists and community resources judiciously.

Family doctors are proactive in advocating healthy public policy.

Family physicians accept their responsibility as key gatekeepers in the health care system by wise stewardship of scarce resources, which considers both the needs of the individual and the community.

Appendix II

Some Useful Websites:

• Students should be familiar with resources that provide critical reviews of the original literature e.g. the Cochrane database accessible from the Outreach Library Site at http://www.lib.uwo.ca/taylor/outreach/.
• Another excellent resource is Bandolier at http://www.jr2.ox.ac.uk/bandolier/index.html.
• The Canadian Library of Family Medicine website is a goldmine of information and links to countless EBM sites and other useful sites including several links to guidleline sites. Log on at http://www.cfpc.ca/English/cfpc/clfm/main/.
• The residents at the Department of Family Medicine in Haifa, Israel have developed a terrific website at http://www.goldenhour.co.il/
• Several excellent journals are available online at no cost. (Your browser must be configured for the UWO proxy server.)
  • Canadian Family Physician http://www.cfpc.ca/cfp/
  • Family Practice: An International Journal http://www.fampra.oupjournals.org/
  • Annals of Family Medicine http://www.annfammed.org/
  • Journal of Family Practice http://www.jfponline.com/
  • BMJ http://www.bmj.com/index.html
  • JAMA http://jama.ama-assn.org/
  • Canadian Medical Association Journal http://www.cma.ca/cmaj/
  • Annals of Internal Medicine
  • Evidence-Based Medicine http://ebm.bmjjournals.com/
  • The Lancet – type "Lancet” in the search window of the Outreach Library.
  • The NEJM http://content.nejm.org/
  • See also the Canadian Library of Family Medicine for additional family medicine journals at http://www.cfpc.ca/English/CFPC/CLFM/journals/.
• Members of the Canadian Medical Association have free access to MDConsult at http://www.cma.ca/index.cfm/ci_id/168/la_id/1.htm. This provides access to a large number of journals, textbooks, guidelines, clinical topic tours, student tip sheets, comprehensive drug information, etc. Access requires free registration.
• The Outreach website of the Allyn and Betty Taylor Library also provides access to many excellent textbooks including Stat!Ref and Harrison’s online. Additional textbooks are available by clicking on "Ebooks”. Go to http://www.lib.uwo.ca/taylor/outreach/.

Appendix III

Presentation Skills:

The following are some tips for effective presentations. The way you present material can help or hinder learning. All physicians are called upon to make presentations to their colleagues, to students and to patients; therefore these skills are essential skills for physicians.

Preamble: Regardless of their area of clinical interest, physicians have an increasing role as managers of health care. Whether speaking in a medical office or a corporate boardroom, presentation skills are necessary to convey important ideas to others. Only through presentations that are effective can physicians have an impact on events that directly affect them and their patients. An effective presentation must make a clear point without taxing the intended recipients of the message. To do this requires considerable preparation and understanding of a few basic strategies.

1. Prepare your discussion well in advance. Have a good idea of the topics you wish to present and plan the time to be assigned to each. Make extra time available if you expect to have questions from the audience or if you will be soliciting their input. Even though you discuss many facts and issues, you should keep in mind that there are one or two main points that you wish everyone to carry away from your discussion. Make sure that everything you say and do relates to these main points.

2. Identify the objectives of the audience. You must try to address your audience's agenda. Try to ascertain it and ensure that it is compatible with your own objectives. You may be able to determine your audience’s interests ahead of time by speaking to a few of the participants.

3. State your objectives from the outset. Ensure that your audience knows what you intend to talk about. It may also help to present a brief overview of your presentation.

4. Maintain eye contact with your audience. Whether you are speaking to three people or to three hundred, try to speak directly to individual members of your audience and move from one to another. You'll look much more natural, and this also helps to overcome fears of stage fright which all speakers feel to some extent.

5. Watch your posture. You should stand erect with heels six to eight inches apart. Do not sway, clench your fists, fold you arms, or use artificial hand gestures. If you wish to move around the room, do so.

6. Speak Clearly. Change the lilt of your voice so it is not presented in a monotone. Emphasize important words with changes in the volume or pitch of your voice. Speak loudly enough to be heard by everyone.

7. Be careful with the terms you use. Avoid language that might be perceived by your audience as being flippant, condescending, derogatory, or insulting to other persons. Satire and sarcasm can be very effective when used appropriately, but can just as easily destroy your presentation if mishandled.

8. If you use visual aids, keep them simple. Any PowerPoint slides or overhead transparencies used should have no more than five important points on them. Large amounts of information tend to make your audience tune out and lose interest. A very effective technique is to include three or four points on each slide or overhead. While it is displayed, you can discuss and elaborate on each of the points in detail. Remember that you can read from the overhead on the projector or a laptop without having to turn your back to the audience. When using PowerPoint, avoid irrelevant animations and flying objects – they distract from your message. You want the audience to look at you most of the time, not the screen. For more tips on PowerPoint, see http://www.infobytes.com/displayarticle70.html.

9. If you use notes, use them correctly. There is nothing wrong with using notes if this is done appropriately. Notes should be in large type and double-spaced so that they are easy for you to quickly glance at. They are a memory aid. They should contain just enough to remind you what you intend to say rather than a complete text for you to read. When you read notes, you lose the conversational style of talking and you may also lose your audience!

10. If you use audiovisual equipment, check it and check it again before you start. You should know how to operate everything you need. Ensure that projection equipment is plugged in, focused, and positioned correctly. You must have a back up plan in the event that equipment fails. At some point in your career, this will happen and you must be prepared to continue your presentation with grace and confidence.

11. Practice

Appendix IV

Examples of excellent student projects:

• Why is this patient on Plavix AND ASA?
• How long should postmenopausal women stay on HRT? (That was before the reports of studies showing the harms of HRT.)
• Is HRT helpful in primary prevention of CAD?
• Is there benefit in early hearing screening?
• How well does the Family Medical Centre follow Pap smear screening guidelines?
• Do antibiotics and other drugs reduce the efficacy of oral contraceptives? What is the evidence?
• What is the evidence supporting the use of routine ultrasound in pregnancy?
• Is there a role for leukocyte esterase testing in the diagnosis of UTI?
• How effective is Pollinex in the management of allergic rhinitis? What is the evidence?
• Critique of the guidelines on management of dyslipidemia. How good is the evidence?
• Prostatitis – pathogenesis, diagnosis and treatment
• Influenza vaccination – how good is the evidence for the Ontario mass screening program?
• Are the guidelines on hypertension sensitive to equity issues?
• Do the medical records reflect the patient-centred clinical method?
• The use of a patient decision aid to enhance finding common ground regarding hormone replacement in post-menopausal women
• The stories of three women who have suffered from abuse – some common themes and suggestions about how physicians can help
• Should family physicians screen for testicular cancer? What is the evidence for benefit vs. harm?