Working with uncertainty in comorbidity

1
Working with uncertainty in co-morbidity

• Group 4
• Bled Course

2
Group 4 Team members

• Mirjam Zemljak (SLO)
• Nilgun Ozcakar (TRK)
• Smiljka Radic (SCG)
• David Manning (UK)
• Davorina Petek (SLO)
• Danica Rotar-Pavlic (SLO)
• Alberto Ferreira de Carvalho (PT)
• Janez Rifel (SLO)
• Gordana Zivcec (SLO)
• Rosa Donncloia (ITA)
• Carmela Zotta (ITA)

3
Objectives

• At the end of the course the learner will
• Understand the limits to certainty in medicine
• Know how to tolerate uncertainty in the care of
  the co-morbid patient
• Know how to assess and communicate risk to
  patients
• Know how to deal with adverse unexpected outcomes

4
Sub-group 1 understanding the limits to
certainty in medicine

• Method mini lecture
• Scenario a man requests an HIV test it comes
  back ve. In threes decide does he have HIV
  infection ?
• Feedback

5
Sub-group 1 understanding the limits to
certainty in medicine

• Interactive talk on probability, sensitivity,
  specificity, prevalence and predictive value
• Diabetes its unpredictability, do we know who
  will get complications.

6
Sub-group 1 understanding the limits to
certainty in medicine

• Assessment
• Short answer question to decide predictive value
  of a positive mammogram

7
Sub-group 2 How to tolerate uncertainty

• Teaching module small group discussion
• Participants trainees
• Setting Family medicine department
• Duration 1 hour and a half

8
Aims

• By the end of the session trainees will be able
  to
• Define areas of uncertainty (patients,
  situations, states )
• Cope with uncertainty
• Consult other physicians or other experts

9
Main activities in workshop

• Introduction of the participants
• Introduction of the scope of the session
• Exploring areas of uncertainty
• Questions
• Define uncertainty
• Discuss meaning of uncertainty
• Prepared case
• Discussion
• Assesment of work and reaching of the aims

10
Prepared caseEven though I have problems and I
know you cant help me Im still coming to see
you.

• M.R. is widowed for 22 years, when her husband
  died in an accident. Her only son died 3 years
  ago in a car accident. She lives alone. Her
  granddaughter is not allowed to visit her after
  the death of her son. She has financial problems
  since she owned a small supermarket with her son.
  She has to pay some debts. There is a question of
  whether she will have to sell her house and go to
  a nursing home.

11
Prepared case

• She has low back pain, paresis of left peroneus,
• 15 years ago she had hernia disci operation and
  now the pains are getting worse and worse.
• She has osteoporosis and two fractures of lumbar
  and cervical spine in her medical history.
• X-ray, MRI and scintigraphy were made by an
  orthopedic surgeon.
• Another operation is suggested to her.
• She is taking ketoprophen, biphosphonate, calcium
  and vitamin D3 supplements.

12
Prepared case

• Uncertainties
• Diagnostics (false positives and negatives)
• Treatment (no inflammation, NSAID?), surgical
  procedure (predicted outcomes)
• Social uncertainty (debts, nursing home)
• Discussion

13
Assesment

• Feedback, evaluation and reflection from the
  participants and group leader (plenary)

14
Sub-group 3 Objective

• At the end of the session, the participants will
  improve their communication skills about
  uncertanty in the medical encounter

15
Sub-group3 - role play How to communicate
uncertainty

• Method role play on specific clinical scenario
• Explore background
• Explore ideas, concerns, expectations
• Discuss possibilities
• All these at level appropriate to patient

16
Method Role play of the prepared case

• 80 year-old retired forrest worker, living alone,
  with history of diabetes, hypertension,
  hyperlipidemia
• Recently suffered hip fracture when he slipped at
  home while trying to take a bath
• After coming from the hospital, after operation,
  he needs asistance for daily activities
• Future improvement with physiotheraphy is expected

17
Assessement checklist

• The expected elements of communication will be
  evaluated on a scale of 0, 1, 2
• 0 not assessed
• 1 partially assessed
• 2 thoroughly assessed

18
Elements of checklist

• Communication on a level acceptable to the
  patient
• Social context of patients life (living
  conditions, contacts with family, friends and
  neighbours)
• Exploration of patients long short term
  expectations, fears
• Exploration of options in management of patients
  physical condition (social wellfare resources,
  nursing home, medical assistance, government
  support, charity assotiations)
• Agreement with patient for the future plan