By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Demonstrate knowledge and skills in the use of Electronic Medical Records and understand how they can support practice improvement
• Demonstrate complete charting for patient care and medicolegal protection (i.e., legibility, pertinent positive and negatives, and clear follow-up instruction)
• Discuss ways to promote teamwork amongst your clinic staff to support your work flow, improve efficiency, and encourage collegiality
• Negotiate role overlap and responsibilities in longitudinal patient centred care (including explanation of own role and responsibilities, active inquiry about others roles and responsibilities, confirmation of understanding)
• Demonstrate proficiency in active team-based care including determining when care should be transferred to another physician or health care provider, safe handover of care and structured approaches to both transitions in care and ongoing shared care
• Manage transitions and transfers of care through clear communication (verbal and written) with all health care providers
• Demonstrate strategies of collaborative leadership
  
• Provide appropriate advice and reassurance regarding common illnesses which do not routinely require medical attention
• Utilize effective documentation to record patient information using medical records that are clear, concise, timely and accessible
• Outline services and resources available to meet the needs of patients in the hospital and community and utilize them appropriately
• Identify barriers to improved health, and accessing resources in the community, and work to ameliorate these barriers
• Integrate community resources to support continuity of patient care including other health professionals, community agencies and groups either within the community or on referral out of the community
• Set priorities and manage time to balance patient care, practice requirements, outside activities and personal life to ensure personal health and a sustainable practice
• Integrate electronic tools into daily practice
• Work collaboratively with MOA, clinic manager and others in a clinic setting in a way that optimizes clinic effectiveness

After spending time with the Portland Hotel Society (PHS), I received feedback on competencies that are challenging for one to confidently know whether or not they're actually being met. One of the comments I received was, "Excellent charting and documentation." It's good to know that my preceptor thought my charting and documentation was "excellent," although by itself it doesn't really indicate what it was that made me competent with this skill. In any case, it is important to document clearly and concisely, making it easily understood by other clinicians, and making sure you have your charting done by the end of the day so that those same other clinicians who may need to obtain information about the visit you had can access any pertinent information readily. (Medico-legally, it is also important to document the advice you provided to patients regarding when are where to receive follow-up medical care and under what circumstances. Like any worthwhile medico-legal documentation, this is just good practice so that you ensure that you take the time to consider and counsel patients on this important piece of advice. It is also important to counsel appropriately about when patients need not re-present for a medical complaint, to spare patients and the health care system the burden of excess unnecessary repeat visits. That being said, it is also good practice to tell patients that if the situation changes - as may occur with a change in the quality or severity of their symptoms - or if they are ever concerned for whatever reason, to always just call or re-present for medical attention.)

​Like a normal human vocabulary, as we grow and learn, we develop new words that can more succinctly describe what it is we want to communicate. It is much the same with medicine as well, and I expect with many other fields of work, where the learner gradually becomes less wordy communicating what is important to their colleagues. This comes along with experience and the development of greater awareness of what it is that your colleagues would appreciate knowing, and in medicine, develops alongside your understanding of what is medically pertinent and not. And this communication really is critical to providing good care when that care is a shared responsibility between many health care providers, much as it is with the Portland Hotel Society clinic and many other newer models of multi-provider care where more than one clinician provides care for a single patient. Even in clinics where each patient has one primary care physician, many of those clinics are making a shift toward a more interdisciplinary clinic model or "Patient's Medical Home" whereby various disciplines are providing a patient with medical care. Effective documentation in this context is requisite for providing effective patient care, and is only going to be more and more important in the interdisciplinary future of our health care system.

The above being said, shared patient care is not a new concept per se either, as family physicians have been referring patients for specialised medical care as long as the discipline of family medicine has itself existed. Even in modern interdisciplinary models such as at the Portland Hotel Society, there may still be the patient whose medical status warrants a more acute level of care than an outpatient clinic can support, and there are patients with such rare diseases that care by a specialist well versed in those disease processes is  ideal. Accessibility to the latter may come with a lag at times, given the number of specialists practicing regionally in a given field of medicine. In any case, such action requires a referral, and the communication may not be in realtime. While I was at the Portland Hotel Society for 2 weeks, each week there was an outpatient I referred urgently to the Emergency Department (I provided a written letter of the circumstances for why I was referring care, as well as providing the important information from the patient's medical chart, expeditiously so thanks to a well-updated EMR system, and providing information so that I could be readily contacted). And each day there was at least one patient who presented after follow-up with a specialist for an uncommon disease process. On one occasion, clarification of the management plan was critical to ensure good patient care for a particularly challenging patient case: We called the Infectious Disease specialist who was managing one of our patients with a new diagnosis of HIV to clarify that our clinic actually had the ability to perform lab work and that the specialist could communicate what they wanted measured and how often so we could obtain this opportunistically when the patient presented (infrequently, to our chagrin) for outpatient medical care. This step meant having an appreciation for the barriers of this patient and the patient population in general to which they belong, and taking steps to mitigate these barriers in ways that are feasible. Spending time with PHS meant furthering my understanding of the extent and consequences of the barriers of patients who are street entrenched, along with seeing creative solutions to many of these barriers. Feedback I received from PHS included, "Thinks about the social determinants of health and the patient context when creating clinical plans," and I believe it was the examples laid out before me that primed my mind to be more sensitive to these barriers than I would have otherwise been. Patients were, for example, linked directly to various community health services beyond those delivered by physicians, with common examples being physiotherapy, mental health counselling, and detox treatment, and this was made possible through strong community connections. Being aware of the various services that different agencies offer and forging strong relationships with the providers of those services means being able to assist patients in accessing helpful services in a timely way. The above examples of inter-provider patient communication, and the ways in which I learned to integrate them into my care of patients on this elective, are what I believe led to the pieces of feedback I received on my evaluation form that state, "Appropriate referrals" and "Liaises with outside care providers to coordinate care." This is important feedback for me to reinforce these actions that are essential to provide good patient care.

Beyond making efforts to document information clearly etc, the medium is also part of what makes the message effective, and Electronic Medical Records (EMRs) are absolutely more effective as a communication and management tool compared to paper charting. (Albeit there is also a time and a place for verbal communication over the phone or in formal meetings, such as family meetings or ones where multiple disciplines and stakeholders are present.) At the Portland Hotel Society, they make effective use of their EMR by not only using it as a platform for effective charting and easy yet private sharing of patient information, but also as a tool to manage their practice, organizing tasks and creating reminders, communicating by tags and coloured alerts to indicate the status of the patient in the clinic (ex: that they are in with the physician, that they are seeing the nurse, that they have checked in and are still waiting to be seen, that their visit is complete but that the documentation from the visit is not finished yet, etc), and notifying various members of the team when there have been referral made to other health care providers, among other functions. I mean, I'll take the piece of feedback saying I was "Thoughtful about work flow and clinic pace," but in all honesty, the system would have made it a challenge not to be. I can't wait to have a future EMR in my practice to make the care I provide practical, efficient, and a heck of a lot more functional than sloppy handwriting on a vulnerable piece of paper.

That being said, by itself, an EMR doesn't by itself make a clinic functional and promote better care, but in a context where these are valued ways of operating and there are policies to benefit from the EMR, it can enhance a team's ability to do their job. The teamwork and collegiality at the Portland Hotel Society was truly exceptional, and even as a learner who was a temporary member of the team, I was welcomed and made to feel valued for the small part I had to play in patient care. An EMR system does not omit the need for the in-person sense of community at the clinic, but it does serve as a platform for continued communication and connection with the team once those relationships are created. I am fortunate to have been a part of the team at the Portland Hotel Society to appreciate how a truly functional health care team values patients and the other members of the interdisciplinary team, by what they communicated, how they communicated, and the little efforts to include each other in patient care when relevant. They also did little things that truly make a difference, like starting the day with a team check in, to ground each other and make space to value our humanity as people as well as employees. And having reasonable work hours, which keeps everyone sane. Alongside feedback regarding my clinical abilities, I received comments like, "A pleasure to work with and have on our interdisciplinary team" and "Respectful and collegial with the team," which is as much an indicator of my abilities to be a team player as it is to suggest how valuing teamwork can bring out those qualities in an organization. 

A big part of residency is indeed learning to manage a very busy schedule and cope with all of life's other demands at the same time. Certainly I have developed  my ability to more efficiently manage the multiple obligations of life beyond the demands of work that are often overwhelming. On the other hand, it has become apparent to me that the expectation of the work environment has a far greater effect on my ability to manage life than my skills to cope with less time. While at the PHS, I presented for work every day feeling recharged and ready to give it my all because I had enough time outside of clinic to read around cases and enhance my knowledge of how to treat the diseases more prevalent in the patient population (my evaluation from the PHS included, "Finished her opioid agonist therapy and injectable opioid agonist therapy courses and preceptorships during this rotation"), and I still had enough time to keep my fridge stocked with fresh food and go for dinner with friends in the evening. When I start working after graduation and join a community clinic, a priority for me will be to join an organization that not only values the Patient's Medical Home model, but one that also values the home lives of all of its team members, enhancing both my patients' and my own quality of life.

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient's cultural and gender contexts, will be able to...

• Exhibit the ability to work collaboratively and effectively within a collegial, multidisciplinary framework of health care delivery, including working with colleagues and institutions from/in other cultures
• Apply strategies to integrate and engage health care profession colleagues in respectful shared decision-making
• Build positive, compassionate therapeutic relationships between patients, families, and health care team members
• Exhibit day to day behaviour that is responsible, reliable, and trustworthy
• Demonstrate effective empathic communication skills in delivery of life-altering news and difficult information
• Recognize limits of clinical competence and seek help appropriately
• Demonstrate accountability to team
• Develop a common understanding on issues, problems, and plans with patients and families, colleagues, and other professionals to develop, provide and follow-up on shared plan of care
• Provide cost effective medical care in decisions regarding hospitalisation, test utilisation and billing, and balancing effectiveness, efficiency, and access with optimal patient care
• Demonstrate confidence without arrogance, and does so even when needing to obtain further information or assistance
• Show respect for patients in all ways, maintain appropriate boundaries, and demonstrate commitment to patient wellbeing

Today I received an evaluation from my month rotation on the Family Practice Teaching Service at St Paul's Hospital. Feedback to check off some of the above items include:

• "Excellent work, liaised well with allied health and family doc in community."
• "Very professional, on time, even often early, reliable"
• "Maddy had a great rapport with her patients and their families. They all knew her by name and looked to her as a leader in their/their family members care. She took care of some very sick patients during the week I worked with her and she managed this well and knows when to ask for help, which is really important when things are not going in the right direction. I observed a goals of care discussion which went well, she was sensitive to the families needs and avoided jargon. A great team member!"
• "Maddy uses many of her canMED roles effectively: eg. a case in ER where hospitalization was avoided due to this residents careful history and physical as well as collaboration with community practitioner ! good stuff"
• "A strong patient advocate!"

I think I milked the feedback for all it was worth and linked it to as many learning objectives as I can ethically feel okay with! 

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient's cultural and gender contexts, will be able to...

• Describe community-based care resources and rehabilitation services available
• Monitor and coordinate care of children with chronic illnesses, disabilities, or serious disease, using available community supports as necessary
• Identify mental health resources in the community and appropriately connect people to these resources
  
• Use referrals, support networks and community resources as part of a patient-centred management plan

Disability
Key Feature 1: Determine whether a specific decline in functioning (ex: social, physical, emotional) is a disability for that specific patient.
Skill: Patient Centered, Clinical Reasoning
Phase: Diagnosis

Today I spent the afternoon in my home family clinic. Within 3 hours of seeing patients, I had developed management plans that included referrals to at least 3 different allied health care professionals, which is pretty standard in a comprehensive family practice. Community resources and professional supports can be extensive in urban centres such as Vancouver, so it really is beneficial to ask patients about what sorts of limitations their medical issues are creating for them - be they social, physical, or emotional - in order to access an extensive network of supports that can make a world of difference. I have always been asking my preceptor whom I am working with if they have a go-to professional or community resource in the indicated area, but it's about time I start building my own database of community-based resources and rehabilitation services to refer patients to. Thanks to a formal lecture given to my cohort of residents near the start of residency, I have some excellent resources to get me headed down a path of less resistance in order to suffice and surpass my patient's allied health and community resource needs. The online resources that I find particularly glorious for (resident) physicians working in British Columbia:

No more excuses for me! Time to explore the options, find some health allies, and be resourceful in this province ripe with community support services.