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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...
Behavioural Problems Key Feature 1: Because behavioural problems in children are often multifactorial, maintain a broad differential diagnosis and assess all factors when concern has been raised about a child’s behaviour:
Phase: Hypothesis generation, Diagnosis Key Feature 2: When obtaining a history about behavioural problems in a child:
Phase: History Key Feature 3: When treating behavioural problems in children for whom medication is indicated, do not limit treatment to medication; address other dimensions (ex: do not just use amphetamines to treat ADD, but add social skills teaching, time management, etc.). Skill: Clinical Reasoning Phase: Treatment Key Feature 4: In assessing behavioural problems in adolescents, use a systematic, structured approach to make an appropriate diagnosis:
Phase: Hypothesis generation, Diagnosis Learning (Patients) Key Feature 2: In children with school problems, take a thorough history to assist in making a specific diagnosis of the problem (ex: mental health problem, learning disability, hearing). Skill: Clinical Reasoning Phase: History, Hypothesis generation Key Feature 3: When caring for a child with a learning disability, regularly assess the impact of the learning disability on the child and the family. Skill: Patient Centered, Communication Phase: Hypothesis generation, Follow-up Key Feature 4: When caring for a child with a learning disability, ensure the patient and family have access to available community resources to assist them. Skill: Patient Centered, Clinical Reasoning Phase: Treatment, Referral Periodic Health Assessment/Screening Key Feature 1: Do a periodic health assessment in a proactive or opportunistic manner (i.e., address health maintenance even when patients present with unrelated concerns). Skill: Clinical Reasoning Phase: Treatment Today I saw three 4 year old kids who came into clinic with their parents for their routine vaccinations before entering kindergarten. These kids were impressive too - not a single one cried when I gave them their immunizations! Needless to say I was having a great day. All kids were healthy and without any history of significant medical concerns. During the last 4 year old visit, per my routine pediatric health check-up, I asked the patient's mom if she had any concerns. She described an odd tapping/pinching behaviour the child would do almost compulsively, which didn't sound so concerning but that was certainly out of the ordinary. I wasn't quite sure what to make of it, but I felt it was significant enough to warrant an assessment by a general pediatrician. At every pediatric check-up, I use either the Rourke Baby Record (ages 0-5 years old) or the Greig Health Record (ages 6-18 years old) to screen for any developmental or behavioural concerns, to promote wellness as opposed to just treating illness, and to obtain any screening investigations if indicated. These templates assess for medical conditions, psychosocial factors, and other developmental issues. I always make sure to include the child or adolescent's perspective as well, and in the latter case I always kick the parent/guardian out of the room to increase my ability to screen for certain issues such as domestic violence or sexually risky behaviours. When concerns are raised I also seek collateral information from other adults who look over the child or adolescent during the day, such as a main daycare or school instructor, as indicated. The reason for the comprehensive screening assessment is to be able to glance over the multitude of risk factors that may be contributing to behavioural concerns, which are more often than not a product of several interacting factors. That being said, it is important that treatments also focus on the multifactorial nature of behavioural concerns; it is rare if not impossible to find a pediatric behavioural concern that is best treated by medication exclusively. It is important to refer these children and adolescents for comprehensive assessments from specialised medical professionals and to build a team of interdisciplinary supports around them, as is feasible and available regionally, and as is tailored to the child's and family's values and interests. Although a small degree of difficult behaviour may be part of the natural development of children as they learn to explore boundaries and create an independent sense of identity, which is particularly true in adolescence, behavioural issues can also be very real manifestations of psychosocial precipitants or medical illness. Any behavioural concerns deserved to be explored and warrant some sort of intervention, whether it be parental reassurance or getting a whole team of community supports in place. As the primary care physician, it is important for me to recognize that issues that affect a child can really be affecting a whole family (not that this isn't true when adults have issues), and to check-in with how the rest of the family is impacted and how they are coping. It is also my job to ensure they have access to useful community resources that may help given their particular set of circumstances.
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UBC Objectives: Palliative Care, Priority Topic: Bad News & Priority Topic: Learning (Patients)8/16/2018 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...
Bad News Key Feature 1: When giving bad news, ensure that the setting is appropriate, and ensure patient’s confidentiality. Skill: Patient Centered, Communication Phase: Treatment Key Feature 2: Give bad news:
Phase: Treatment Key Feature 3: Obtain patient consent before involving the family. Skill: Patient Centered, Professionalism Phase: Treatment Key Feature 4: After giving bad news, arrange definitive follow-up opportunities to assess impact and understanding. Skill: Patient Centered, Communication Phase: Follow-up Learning (Patients) Key Feature 5a: To maximize the patient’s understanding and management of their condition: Determine their willingness to receive information. Skill: Patient Centered, Communication Phase: Diagnosis, History Key Feature 5b: To maximize the patient’s understanding and management of their condition: Match the complexity and amount of information provided with the patient’s ability to understand. Skill: Communication, Patient Centered Phase: Treatment Throughout my residency training, I have seen physicians break bad news in wildly different ways. This week, I spent time with a urologist who barged into a room where a patient and his wife appeared to be anxiously awaiting to find out whether or not the data on his prostate suggested an increased risk of prostate cancer. Before even sitting down, he said "Yup, your prostate looks suspicious for cancer." And then as he propped himself into the chair casually he said, "We're gonna need to get a biopsy of it. Just make your way to the front desk and the receptionist will help you with the forms." And out he zipped. He literally spent less then 1 minute in the room. I looked with despair at the patient sitting with his eyes wide open, while his wife's mouth gaped open. As I followed my preceptor out of the room, I watched as the wife turned to her husband and explained what the urologist said but this time in Cantonese. By the time the patient understood what was even said, the urologist was long gone. What the HECK was that. Yes, surgeons are notorious for having poor bedside manners, but earlier this year I witnessed a general surgery resident breaking bad news in the most caring and compassionate way I have ever seen. He explained to the patient what the circumstances were without jargon, he confirmed that the patient understood, and he provided space for questioning. He gave time to ensure comfort of the patient, and obtained legitimate informed consent, something that is not often done well in the hustle and bustle of day-to-day medicine, let alone for the ultra fast pace of surgical medicine. To contrast the two cases, the urologist was a man who I believe is almost ready to retire, while the surgeon-in-training is of a generation being trained to provide patient-centered care. Although there are many exemplary experienced physicians who break bad news with utmost compassion, and many young MDs who lack life experience and the empathy this endows, new physicians are graduating being expected to demonstrate the competency of breaking bad news in a patient centered way. It is an important modifiable factor in creating or curbing harm that can result from devastating news. Certain rules of thumb are pervasive in medicine and the SPIKES mnemonic is the catch-phrase all junior medical doctors are taught to break bad news compassionately and effectively. SPIKES
There are many ways the individual physician can mesh these points with their own practice style to have an authentic approach to breaking bad news. Certainly the urologist didn't, and certainly the general surgery resident went above and beyond. As a physician-in-training, I work with many stellar and occasionally not-so-stellar role models, learning how to provide good care and also witnessing where care falls short, or in this case with the urologist, how it may be the exact opposite of what I am taught to do. While I sometimes cringe at the impact this has on the patients in front of me, it will at least hopefully serve to provide me with reinforcement of the importance of holding high standards of care and not becoming so familiar with disease processes that the impact they have on a patient's lived experience is forgotten. By the end of postgraduate training, using a patient-centered approach and appropriate selectivity, a resident, considering the patient's cultural and gender contexts, will be able to...
Learning (Patients) Key Feature 1: As part of the ongoing care of children, ask parents about their children’s functioning in school to identify learning difficulties. Skill: Clinical Reasoning Phase: History Newborn Key Feature 6: In caring for a newborn ensure repeat evaluations for abnormalities that may become apparent over time (ex: hips, heart, hearing). Skill: Clinical Reasoning Phase: Follow-up, Physical Key Feature 7a: When discharging a newborn from hospital: Advise parent(s) of warning signs of serious or impending illness. Skill: Clinical Reasoning, Communication Phase: Treatment, Follow-up Key Feature 7b: When discharging a newborn from hospital: Develop a plan with them to access appropriate care should a concern arise. Skill: Clinical Reasoning, Patient Centered Phase: Follow-up Obesity Key Feature 7: As part of preventing childhood obesity, advise parents of healthy activity levels for their children. Skill: Clinical Reasoning Phase: Treatment Poisoning Key Feature 1: As part of well-child care, discuss preventing and treating poisoning with parents (ex: “child-proofing”, poison control number). Skill: Communication, Clinical Reasoning Phase: Treatment Well-baby Care Key Feature 1: Measure and chart growth parameters, including head circumference, at each assessment; examine appropriate systems at appropriate ages, with the use of an evidence-based pediatric flow sheet such as the Rourke Baby Record. Skill: Clinical Reasoning, Psychomotor, Skills/Procedure Skills Phase: Physical Key Feature 4: At each assessment, provide parents with anticipatory advice on pertinent issues (ex: feeding patterns, development, immunization, parenting tips, antipyretic dosing, safety issues). Skill: Clinical Reasoning Phase: Treatment Key Feature 5: Ask about family adjustment to the child (ex: sibling interaction, changing roles of both parents, involvement of extended family). Skill: Patient Centered Phase: History Key Feature 8: Even when children are growing and developing appropriately, evaluate their nutritional intake (ex: type, quality, and quantity of foods) to prevent future problems (ex: anemia, tooth decay), especially in at-risk populations (ex: the socioeconomicaly disadvantaged, those with voluntarily restricted diets, those with cultural variations). Skill: Clinical Reasoning Phase: History, Treatment A well baby is always a good thing! And having an easy and trustworthy method of knowing whether a baby is well is a double good thing. In medical school we were taught we needed to memorise the extensive list of childhood developmental milestones and remember just how many ounces of formula per kg of weight infants need. We were taught to always perform a comprehensive physical examination during a well child checkup, but one that included only the relevant manoeuvres, which tended to change as quickly as you went from one preceptor to the next. BUT THERE IS A BETTER, MORE EVIDENCE-INFORMED, MORE EFFICIENT, AND LESS STRESSFUL WAY. The Rourke Baby Record is an evidence-based pediatric flow sheet that assists physicians in assessing and documenting the routine well-child checkup. It is based on age and can be integrated into electronic medical records. It is my friend, and it's got my back with its guide to interpretation of what is considered within normal limits. The website has links to the WHO growth charts as well, if it wasn't already schmoozing me enough. Furthermore, it provides a template* for the entire encounter, prompting information gathering and anticipatory guidance as relevant to the child's age. With handouts for parents and a list of relevant resources for different-age related concerns (including for the initial discharge from hospital after delivery), along with evidence-informed recommendations for all of the anticipatory guidance you could dream of, no wonder these kids as displayed on their website are as happy as I am!  *Being a template for a generic encounter, it is important for the clinician to be astute in modifying the encounter as needed. For example, one of the prompts for information gathering in the first month of life is inquiry into siblings. I consider this to be a prompt to assess how others in the family in general, including but not limited to siblings, are adjusting to the new family member. This may include how parental roles are being affected, and who in the extended family is offering support. The RBR is a stimulus for a conversation, but should not be considered a literal and exhaustive encounter script. And, when it comes to physical exam maneuvers that aren't as enjoyable, like measuring head circumference or length, or assessing hip stability, I perform these opportunistically or else altogether at the end of the visit so that I disturb the child as little as possible. The template ensures you obtain the important clinical information, but I can choose how to acquire the most information and with more rather than less tact.
Once children are older than 5 years old, switch out your RBR for the Greig Health Record and you can continue on your merry way until a child has reached adulthood. |
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