medical anecdotal report as a teaching-learning tool to develop holistic, professional and...

Medical Anecdotal Reports as a Teaching-Learning Tool to Develop

Holistic, Professional and Compassionate Physicians

Reynaldo O. Joson, MD, MHA, MHPEd, MSc Surg

Annual Conference of Tripartite Training Institution in Manila

March 27, 2015

Medical Anecdotal Reports as a Teaching-Learning Tool to Develop Holistic,

Professional and Compassionate Physicians

April 2004

I started a project - Medical Anecdotal Reports (MAR)

Department of Surgery of Ospital ng MaynilaMedical Center (OMMCSurg)



MAR -

additional innovative teaching-learning activity

that I had designed for the Department

during my term as Chairman from 2001 to 2009



MAR - operationally defined

as a brief written report on an actual medical event

that involves an actual patient seen by a surgical resident or trainee.



The medical observation must have

an impact on the surgical resident as a

physician in terms of

insight gained and

which he/she thinks is worth sharing with

colleagues as this

may help improve patient care and

may be useful for the knowledge management

system of the Department.



In essence,

MAR is a reflection paper

and

writing it is a reflective learning activity

for the surgical residents or trainees.



From April 2004 up to the time of my retirement in

January 31, 2014,

the objectives, policies and implementing instructions on the MAR

have been continually refined.



As to objectives,

MAR - primarily a learning activity in the development of holistic, professional, and compassionate physicians among

the surgical residents of OMMCSurg.

2nd objective - to enhance the residents’ English writing skills.

3rd objective - to reinforce Department’s knowledge management system through the issues raised and resolutions made in MAR activity.



As to policies and implementing instructions,

each resident is required to write and present

one MAR a month,

except in January and December, the respite period.



A template is used for the writing and presentation

of the MAR

which consists essentially of a one-page paper with

narration followed by

insight and categorization of the latter into

physical, professional /ethical, and psychosocial domain.



For every presentation of a MAR,

at least 2 residents are required to react

with a consultant moderating and facilitating discussion.

Feedback and discussion cover both

contents and technical writing of the MAR.



At the conclusion of each MAR presentation and discussion,

resolutions are made on measures to be adopted

by the Department staff

in enhancing the development of holistic, professional, and compassionate physicians as well

as

in improving the system of care, not only of the Department but also of the entire hospital.



Sample of a short MAR



Indexing Title: JGGuerra’s Medical Anecdotal Report (08-04)

MAR Title: “How to deal - when you have lost a patient”

Date of Observation: March, 2008



Narration:

It was a relatively not so busy night. As I was about to take my Emergency Room post nearing midnight, the public address system called my attention “ Dr Gray, Dr. Gray to Surgery Emergency Room please!”

I told myself, just another dying patient, perhaps a vehicular accident victim, stabbed victim or worse gunshot victim.

Well, what’s new?



Narration:

When you often see dying patients day in and day out, it becomes a conventional thing.

You get easily detached from the situation. It was always like watching a film or a story being told on a third person point of view, the only difference is that, it was happening right in front of you.



Narration:

I dashed quickly to the Emergency Room, and saw a fairly young looking man, at his early thirties, bathed and soaked in his own blood.

A gun-shot-wound victim, point of entry: right mid-hemi-abdomen.

Blood pressure was palpatory, cardiac rate, barely audible.



Narration:

My plan: resuscitate and do emergency laparotomy.

However, patient continuously deteriorated.

Cardio-pulmonary resuscitation went on as usual, fifteen to twenty minutes of bagging and chest compressions.

Electrocardiogram ran flat, and now the pronouncement, the moment of explanation to the loved ones.



Narration:

The wife was hysterical.

After talking to the relative and perhaps the victim’s wife, I learned that the patient was about to fetch his wife to go out for an anniversary date.

Unfortunately he was robbed and allegedly resisted causing his own life.



Insight: ( Discovery, Stimulus, Reinforcement / (Physical, Psychosocial, Ethical)

The post cardiopulmonary resuscitation scene hit me.

It is one of those moments that would always remind me that losing a patient in your own hand is not merely an ordinary event- a conventional thing.

In every life that is lost, a grieving family is left behind.




I felt a sense of guilt that I should have saved his life.

I felt bad for him that night not only because I was sad for his loss, but more so because I felt my physical limitation as a doctor.

As much as I would like to save lives, death seemed to be inevitable.




Sometimes, as I witnessed death and human drama unfold right into my eyes, situations that I can not do anything but watch how my patient battled for his/her life and loss, I kept questioning myself is there a way to prevent this from happening? Perhaps none…

The best way is to accept reality- our limitation as doctors…



Project MAR is still ongoing and continued

by the current Chairperson, Dr. Hazel Z. Turingan.

For this, I thank her.



A total of 50 surgical residents have written a MAR since 2004.

A resident who completed 5 years of training in OMMCSurg is expected to have written 50 MARs (10 MARs per year x 5).

Since April 2004 (when I started the Project) up to November 2014,

we have roughly 1700 MARs currently in our archive.



There have been a series of evaluations done on the Project MAR since 2004 up to present.

The result of the first formative evaluation was presented in the 4th Asia-Pacific Conference on Problem-based Learning in Health Sciences in September of 2004.

Subsequent ones, in 2006, 2012 and last month.



There were delightful feedback from external sources.

I shall present these evaluation results and feedback in a little while.



With the positive findings of usefulness in improving trainees’ competency in biopsychosocial management of

patients and with delightful feedback on the MAR,

I decided to publish the MARs into a book or books.

I have published two books so far,

one in 2013 and

another one in 2014.

I intend to publish more.



I will now present some delightful feedback from external sources.

In a little while, I will ask a resident to present the results of feedback from OMMC Surg current residents, graduates and consultants.

I will also ask her to present her insight on MAR as a teaching-learning tool.

Likewise, the Chief Residents of Manila Doctors Hospital and ManilaMed will present a 5-minute reaction each on

MAR as a teaching-learning tool for surgical residents.



Delightful feedback from external sources:

Daniel Ong Kian Kok (Jose Reyes Memorial Medical Center) 2014: He asked for an extra copy of Volume 1 and will ask the Department of Surgery of JR to adopt it.

Edgardo Penserga (General Surgeon) – 2014: MAR should be part of the General Surgery curriculum.


Professional and Compassionate PhysiciansDelightful feedback from external sources:

I am touched by your efforts to make your residents so aware of their deeper emotional reactions to the complex situations

they are in and the wonderful people they come in contact with.

More so to find beauty in the midst of destruction, misery and suffering. The practice of medicine, surgical and non surgical, is a dangerous ground for

doctors as it is a field that can make one feel so powerful, dominant, critical and insensitive to self and others.

I feel embarrassed that you the surgeon has done a “sensitivity” program while I have not done my bit to

contribute to make our work more humane and meaningful to others but more so to ourselves.

You are an inspiration. Thank you. You deserve the accolades and recognition.

Connie Salazar-Aleta, MD

Psychiatrist, February 16, 2005



Delightful feedback from external sources:

Hi! I rarely open my email. Just got to read your anecdotal reports. Kudos!

It’s something even we in the field of Psychiatry don’t even do. I might just do that with the psych residents.

Thanks for the heart & the inspiration.

Laureen Conanan, MD

Psychiatrist

April 25, 2005


Professional and Compassionate PhysiciansDelightful feedback from external sources:

Convey to Dr. Guerra that I was impressed and liked very much his anecdote “Beyond Hospital Walls.”

It is very true that good patient care transcends hospital walls!!

His article coincides perfectly with what I have always been teaching my students and residents on the ethical values of

personalized patient care.

Unfortunately, today, as I saw it in our own PGH, patient care by some of our doctors has become too mechanical and the human

touch is LOST.

I hope more residents will read Dr. Guerra’s article and again.

Kudos to you for stimulating your residents to come up with much needed and thought provoking anecdotes like Dr. Guerra’s.

Antonio Limson, MD

General Surgeon, March 1, 2005



The history of the MAR can be seen in the following website: (https://sites.google.com/site/medicalanecdotalreports/histor

y-of-mar-in-ommc-surgery).

Others:

MAR Volume 1: https://medicalanecdotalreportsvol1.wordpress.com

MAR Volume 2: https://medicalanecdotalreportsvol2.wordpress.com

https://sites.google.com/site/medicalanecdotalreports/history-of-mar-in-ommc-surgery

https://medicalanecdotalreportsvol1.wordpress.com/

https://medicalanecdotalreportsvol2.wordpress.com/

Medical Anecdotal Reports as a Teaching-Learning Tool to Develop Holistic, Professional

and Compassionate Physicians

Statements on OMMC Surgery Medical Anecdotal Reporting (MAR)

SA A UnC D SD

The MAR is a form of learning through reflection.

15

Through the MAR, I can reflect on significant insights derived from patient encounters, acquire learning, and share them with my colleagues.

15

Through the MAR, I was able to experience and fully grasp the concept of learning through reflection.

15




SA A UnC D SD

Through the MAR, I have developed the habit to put importance on all aspects of physician-patient biopsychosocial interaction and to analyze them for insights and my continuous learning.

14 1

MAR as a reflective learning tool is a very stronglearning strategy in patient care.

15

MAR as a reflective learning tool has helped me discover things in patient care that I have not known or realized before.

15




SA A UnC D SD

MAR as a reflective learning tool has helped reinforced the philosophies and principles on patient care that I have held before.

15

MAR as a reflective learning tool has helped me change the philosophies and principles on patient care that I have held before.

14 1

MAR as a reflective learning tool has provided me the stimulus for further learning, research, and investigations on patient care.

15


and Compassionate PhysiciansStatements on OMMC Surgery Medical Anecdotal Reporting (MAR)

SA A UnC D SD

Though frowned upon as a basis for decision-making in patient management, experience and insight derived from MAR, when properly used, can serve as basis for patient care.

15

The insights and learning acquired through MAR can supplement or complement the guidelines derived from conventional evidence-medicine methodology in patient care.

15



SA A UnC D SD

MAR-initiated practice guidelines such as how to deal with indigent patients, “irrational” patients, conflict in management with medical colleagues, etc. can facilitate training of residents in developing their relational competency and in their day-to-day management of patients.

15

MAR is a form of narrative medicine defined as “medicine practiced with narrative competence and marked with an understanding of these highly complex narrative situations among doctors, patients, colleagues, and the public.” (Dr. Rita Charon of Columbian University)

15



SA A UnC D SD

Through the sharing of MAR, I can help my colleagues improve on their patient care.

15

Through the MAR, I have improved on my patient care as a whole.

15

Through the MAR, I have placed more emphasis on the psychosocial care of patient and have improved on this aspect.

14 1



SA A UnC D SD

Through the MAR, I have become more aware of the bioethical issues involved in patient care and have felt improvement in this aspect of my patient management.

15

Through the MAR, I have improved on the care of the physical aspect of my patient’s problem.

14 1

Through the MAR, I have improved on my relational skills with my patients, their relatives, my colleagues, and my superiors.

15




SA A UnC D SD

Through the MAR, I was given the opportunity to be more expressive.

15

Through the MAR, I was given the opportunity to polish my written communication skills.

15

Through the MAR, I have improved on my English composition skills.

15

The MAR can serve as an evaluation tool of student’s learning.

15

Through the MAR, the cognitive domain of competency of the students can be evaluated.

15




SA A UnC D SD

Through the MAR, the affective domain of competency of the students can be evaluated.

15

The MAR has contributed to my discipline in terms of following instructions and formats.

15

The MAR has contributed to my discipline in terms of submitting my report on time.

15

Overall, I am satisfied with the MAR of OMMC Surgery.

14 1

I recommend we maintain the MAR but we should keep on refining to make it more effective and efficient.

15



• I like the idea of The MAR as being included in our curriculum as it stimulates us to our discipline not only in fulfilling our requirements but in dealing with our patients as guided by the principles that we learn from the experiences that others share through their MAR.

What I like most? - Residents of OMMC Surg

Sheena Siapno-Feliciano, MD



• MAR help me in reflecting my patient care and improving patient management and care.

• Being allowed to express myself and my experience is the thing I like most in our MAR because residents need an avenue where we can breathe out our thoughts and reflections on our day-to-day encounter with patients, hospital staff and colleague.




• What I like most in the OMMC Surgery MAR is the fact that we can individually share our own experiences in our daily lives as physicians with our patients, in many different aspects, whether it may be a physical, a professional, ethical, or a psychosocial matter. The Surgery Residents who were not able to experience a certain event can be able to learn and pick a lot of things from the other residents' experiences, and be able to apply them to their work promoting a more efficient physician-patient relationship.




• I like most about MAR is that it develops my communication skills in terms of expressing my self in writing and sharing it the general public. It gives me ways to improve on how I interact with different kind of patients and improve my patient management.

• MAR has given me the opportunity to learn more about my co-residents, through the stories they tell and the insights that they share with us.




• I like that through it i am able to write and compose. It give me the opportunity to share my experiences and what I've learned/gained/discovered from such through a literary form. It also provides me a platform to continually improve on many aspects, be it in writing or composing skills or in upholding the core values of the department through patient interaction.




• In the OMMC surgery MAR, we were able to develop our skills in patient relations, care, communication, attitude, and patient-doctor relationship perception. We all have learned to express ourselves full and be able to generate a process of analysis in every relationship we have with our patient, co-resident, seniors and consultants, and most especially, ourselves. I have learned the value of conveying my thoughts to my peers and family so they may understand the life of patients, doctors, through these experiences we have with them. I have improved greatly in English writing, and language.




• The MAR allowed me as a resident to further examine my manner of interaction with both patients and colleagues. It made me more careful of my words and actions when faced with problematic patients and colleagues. As a whole it allowed me to develop a more professional way of interacting with people in the hospital.




• Contemplates aspects of medicine not commonly taught and discussed.

• The opportunity to reflect, think and rationalize especially during decision making, MAR will help u become a better surgeon, better leader and more compassionate to patients.

• Insight sharing from the residents and facilitators From this part, must know informations, experiences and teachings are being shared to each and everyone witnessing the MAR.

• Effective learning tool both for technical/ decision making and psychosocial skills

What I like most? - Graduates of OMMC Surg



• OMMC Surgery MAR made us residents to develop our writing skills. In a way that this gave us confidence in our work such as reports and in conferences.

• What I like most about making and eventually evaluating MARs done by others, is being able to scrutinize aspects of being a surgeon ( relationships - colleagues, paramedical, patients; administrative difficulties) and see all these things first subjectively then objectively. A small area of training that one might take for granted if not forced to be analyzed by writing the experience as a MAR. And once the MAR is written, it becomes a part of your internal learning not to be forgotten.




• As I read MARs done by residents, I not only get to be aware of the dilemmas they face during training but through the sharing of their experiences, I get to know the residents intimately. And what I see is inherent goodness and the urge to do good. And I am not only strengthened that we have done right by them but also hopeful about the future of the training program.




• The Insight because of the lessons we learned on every MAR Report.• Effective learning tool both in terms of clinical competence and

relational skills/psychosocial aspects in managing patients.• When it tackles subject related to compassion. Because it brings out

the Hippocratic physician in me.




Closing:

There you are – The Medical Anecdotal Report as a Teaching-Learning Tool to Develop Holistic, Professional and

Compassionate Physicians.

Think about it.

You may want to adopt it in MDH and ManilaMed.

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