An Innovative Program to Teach First and Second An Innovative Program to Teach First and Second Year Medical Students about the Impact of Chronic Year Medical Students about the Impact of Chronic

Illness on Patients and FamiliesIllness on Patients and Families

Sharon A. Mueller, RN, MA; Kendall Reed, Sharon A. Mueller, RN, MA; Kendall Reed, DO; Mary-Pat Wohlford-Wessels, Ph.D.DO; Mary-Pat Wohlford-Wessels, Ph.D.Des Moines University- Osteopathic Des Moines University- Osteopathic

Medical CenterMedical CenterDes Moines, IowaDes Moines, Iowa

The Chronic Care The Chronic Care Program:Program:

C.O.P.E./Community Osteopathic C.O.P.E./Community Osteopathic Professional Education Program Professional Education Program at Des Moines Universityat Des Moines University

Abstract:Abstract:

The Chronic Care /Community The Chronic Care /Community Osteopathic Professional Osteopathic Professional Education/C.O.P.E. program was Education/C.O.P.E. program was implemented in the Spring of 2004. implemented in the Spring of 2004.

It was developed to introduce first It was developed to introduce first and second year medical students to and second year medical students to patients dealing with chronic patients dealing with chronic illness, while fostering illness, while fostering compassionate health care.compassionate health care.

C.O.P.E.C.O.P.E.

This elective has grown to the point This elective has grown to the point that 30% of first and second year that 30% of first and second year students are enrolled.students are enrolled.

Patients enrolled are referred by Patients enrolled are referred by community physicians and caregivers.community physicians and caregivers.

Students learn more about chronic Students learn more about chronic illness as it affects real people.illness as it affects real people.

Students study a variety of Students study a variety of diseases.diseases.

C.O.P.E.C.O.P.E.

Students learn about diseases such Students learn about diseases such as: congestive heart disease, as: congestive heart disease, chronic obstructive pulmonary chronic obstructive pulmonary disease, diabetes, multiple disease, diabetes, multiple sclerosis and Parkinson’s Disease.sclerosis and Parkinson’s Disease.

Students learn about the Students learn about the psychological, financial and psychological, financial and interpersonal impact of these interpersonal impact of these various diseases, in addition to various diseases, in addition to the traditional curriculum.the traditional curriculum.

CompetenciesCompetencies::

A survey of 1,236 physicians, A survey of 1,236 physicians, revealed that chronic disease revealed that chronic disease training was less than adequate (1). training was less than adequate (1). Sixteen course directors at U.S. Sixteen course directors at U.S. medical schools concluded that medical schools concluded that schools should include specific schools should include specific methods for the development of methods for the development of chronic care competencies among chronic care competencies among students (2). Dr. Michael Whitcomb, students (2). Dr. Michael Whitcomb, in in Academic Medicine Academic Medicine suggests a suggests a specialty be developed.specialty be developed.

Career Choices:Career Choices:

Fewer students are choosing a Fewer students are choosing a career in Primary Care, career in Primary Care, therefore, Dr. Whitcomb therefore, Dr. Whitcomb suggests a type of “generalist” suggests a type of “generalist” specialty to be name specialty to be name “Practitioner of Comprehensive “Practitioner of Comprehensive Medicine” (3)Medicine” (3)

How does my education How does my education apply to realapply to real people??people??

This is the question many students This is the question many students ask, as they attempt to master the ask, as they attempt to master the basic sciences and apply them to basic sciences and apply them to clinical practice.clinical practice.

How to add more to an already How to add more to an already crowded curriculum???crowded curriculum???

As an elective, students signed up As an elective, students signed up in large numbers, to add to their in large numbers, to add to their understanding of “real patients” understanding of “real patients” with “real illnesses”with “real illnesses”

Referrals from Referrals from Community:Community:

Physicians and Caregivers from the Physicians and Caregivers from the Des Moines community refer patients.Des Moines community refer patients.

Students are sent in pairs to visit Students are sent in pairs to visit patients in their homes, Dr’s patients in their homes, Dr’s offices, treatments centers and the offices, treatments centers and the hospital.hospital.

Physicians and Caregivers are in a Physicians and Caregivers are in a unique position to instruct and unique position to instruct and model how to provide appropriate model how to provide appropriate care to these individuals.care to these individuals.

Documentation:Documentation:

Students are required to visit Students are required to visit every 4-6 weeks and document every 4-6 weeks and document their visits in SOAP note format.their visits in SOAP note format.

Students are encouraged to Students are encouraged to journal about their experiences.journal about their experiences.

Students also meet in small Students also meet in small groups with faculty facilitators groups with faculty facilitators every other month, to discuss every other month, to discuss their various experiencestheir various experiences

Relationships:Relationships:

Students get to know their Students get to know their patients really well and are patients really well and are able to share their insights able to share their insights into chronic care, reflect on into chronic care, reflect on what they have learned and set what they have learned and set goals for future visits.goals for future visits.

Appreciation Reception:Appreciation Reception:

The past two years, we have The past two years, we have held an “Appreciation held an “Appreciation Reception”, inviting patients, Reception”, inviting patients, caregivers, physicians, faculty caregivers, physicians, faculty and staff to participate. This and staff to participate. This year we had a speaker from the year we had a speaker from the community about Chronic Care of community about Chronic Care of the patient with Pulmonary the patient with Pulmonary Disease.Disease.

What we have Learned:What we have Learned:

Each year, in May, we administer an Each year, in May, we administer an evaluation on Blackboard. This evaluation on Blackboard. This includes such questions as, the includes such questions as, the importance of the subject, value of importance of the subject, value of the small group, effectiveness of the the small group, effectiveness of the facilitators, ability to interact with facilitators, ability to interact with and observe patients and their and observe patients and their significant others during the course significant others during the course of their illness, relationship with of their illness, relationship with physicians, etc.. The following slide physicians, etc.. The following slide shows last years results.shows last years results.

EVALUATION:EVALUATION:Q u e s t io n : P a r t i c ip a t i n g i n t h i s c o u r s e

e n h a n c e d m y a b i l i t y t o :

A v e r a g e S c o r e S c o r in g B a n d

b e t t e r u n d e r s t a n d t h e p s y c h o s o c i a l im p a c t o f c h r o n i c i l l n e s s o n p a t i e n t s a n d t h e i r f a m i l i e s .

2 . 9 5 G o o d P r o g r e s s

o b s e r v e t h e f a m i ly d y n a m ic s , f i s c a l im p a c t , h o m e c a r e i s s u e s , p r im a r y c a r e - g iv e r

r e s p o n s ib i l i t i e s p a l l i a t i v e c a r e a n d e n d o f l i f e i s s u e s .

2 . 9 4 G o o d P r o g r e s s

t a k e a b a s i c h i s to r y a n d d e v e lo p p a t i e n t d o c u m e n ta t i o n .

2 . 5 8 G o o d P r o g r e s s

c o m p le t e a n i n i t i a l a s s e s s m e n t o f f a m i ly

d y n a m ic s .

2 . 6 6 G o o d P r o g r e s s

d e v e lo p a c a r in g r e l a t i o n s h ip w i th a f a m i ly a n d a p a t i e n t w i th c h r o n i c i l l n e s s

2 . 9 5 G o o d P r o g r e s s

d e v e lo p a p r o f e s s io n a l r e l a t i o n s h ip w i th a p r im a r y c a r e p r o v id e r

1 . 8 8 L i t t l e P r o g r e s s

d e v e lo p a n i n - d e p th k n o w le d g e o f a p a t i e n t ’ s p r im a r y d i s e a s e a s w e l l a s a n y c o - m o r b id i t i e s

2 . 8 2 G o o d P r o g r e s s

c o m m u n ic a t e w i th t h e p r im a r y c a r e p r o v id e r a t

l e a s t m o n th ly b y p h o n e , e - m a i l o r i n p e r s o n t o e v a lu a t e t h e p a t i e n t ’ s p r o g r e s s a n d p l a n o f

t r e a tm e n t

1 . 7 3 L i t t l e P r o g r e s s

r e v i e w o v e r a l l m a n a g e m e n t i n c lu d in g m e d ic a l

a n d s u r g i c a l t r e a tm e n t s , a s w e l l a s m e d ic a t i o n s , l a b o r a to r y s tu d i e s a n d o th e r s e r v i c e s p r o v id e d

t o t h e p a t i e n t .

2 . 3 6 L i t t l e P r o g r e s s

u n d e r s t a n d t h e p r o c e s s o f p a l l i a t i v e c a r e a n d t h e e n d - o f - l i f e i s s u e s f a c in g a p a t i e n t a n d

f a m i ly

2 . 4 4 L i t t l e P r o g r e s s

d o c u m e n t t h e e x p e r i e n c e b y u s in g S O A P n o te s

a s w e l l a s j o u r n a l i n g

2 . 4 8 L i t t l e P r o g r e s s

Discussion:Discussion: In assessing the evaluations, it was In assessing the evaluations, it was decided to add a bit more structure to decided to add a bit more structure to the curriculum, i.e., have case the curriculum, i.e., have case presentations at the end of the year; presentations at the end of the year; change the course to credit, vs. no-change the course to credit, vs. no-credit, along with a reference to credit, along with a reference to participation in the student’s Dean’s participation in the student’s Dean’s letter, prior to rotations/residencies.letter, prior to rotations/residencies.

We added DPT students to the mix, due to We added DPT students to the mix, due to the support given by Facilitators from the support given by Facilitators from the PT Dept.the PT Dept.

Also, this adds a nice mix of viewpoints.Also, this adds a nice mix of viewpoints.

Discussion Cont’d:Discussion Cont’d:

We applied for a Grant, however, we We applied for a Grant, however, we were approved, but not funded, due to were approved, but not funded, due to cutbacks in the budget for NIH and cutbacks in the budget for NIH and various other agencies.various other agencies.

The University continues to support The University continues to support the program, due to it’s popularity the program, due to it’s popularity and usefulness, over 100 students and usefulness, over 100 students continue to be enrolled, each semester continue to be enrolled, each semester – more than any other elective.– more than any other elective.

The program is seen as necessary.The program is seen as necessary.

Restructuring:Restructuring:

Intitially the program/C.O.P.E., fell Intitially the program/C.O.P.E., fell under the auspices of the Dean of the under the auspices of the Dean of the C.O.M., however, it was decided it C.O.M., however, it was decided it would fit well in the Geriatrics would fit well in the Geriatrics Department, where we also have a Department, where we also have a number of electives and the Geriatric number of electives and the Geriatric Education Center (GEC) at DMU. The Education Center (GEC) at DMU. The Medical Director is also involved Medical Director is also involved with Hospice of Central Iowa, an with Hospice of Central Iowa, an added benefit being “end-of-life” added benefit being “end-of-life” issues.issues.

References:References:

1) Darer, J.D., Hwang, W., Pham, H.H., 1) Darer, J.D., Hwang, W., Pham, H.H., Bass, E.B., Anderson, G. (2004). More Bass, E.B., Anderson, G. (2004). More training Needed in Chronic Care: A training Needed in Chronic Care: A Survey of US Physicians. Academic Survey of US Physicians. Academic Medicine, 79(6); 541-8.Medicine, 79(6); 541-8.

2) Bodenheimer, T. (2003). 2) Bodenheimer, T. (2003). Interventions to improve Chronic Interventions to improve Chronic Illness Care: Evaluating their Illness Care: Evaluating their Effectiveness. Disease Management, Effectiveness. Disease Management, 6(2); 63-71.6(2); 63-71.

References cont’d:References cont’d: 3) Whitcomb, Michael E. (2005). 3) Whitcomb, Michael E. (2005). Who’s Going to Take Care of the Who’s Going to Take Care of the Folks? Academic Medicine, 80(9); Folks? Academic Medicine, 80(9); 789-90.789-90.

4) Bankston, Patrick W. (Class of 4) Bankston, Patrick W. (Class of 2006-07). Indiana University School 2006-07). Indiana University School of Medicine-North-west. Academic of Medicine-North-west. Academic Program, Problem-Based Learning (PBL) Program, Problem-Based Learning (PBL) Curriculum. The 7 Steps of the PBL Curriculum. The 7 Steps of the PBL Curriculum (Doctor-Patient Curriculum (Doctor-Patient Relationship-dispersed throughout the Relationship-dispersed throughout the first year). Gen. Info.first year). Gen. Info.

THE END!!!THE END!!!

AACOM Conference:AACOM Conference:

Baltimore, MD, June 22-25, 2006Baltimore, MD, June 22-25, 2006

Thank You very much:Thank You very much: Sharon.Mueller@dmu.eduSharon.Mueller@dmu.edu, 515-271-, 515-271-10941094

Director, Chronic Care, Des Moines Director, Chronic Care, Des Moines UniversityUniversity

3200 Grand Avenue, Des Moines, IA 3200 Grand Avenue, Des Moines, IA 5031250312