Learning medicine through a multi-disease framework. KM Weston, JA Bushnell, JN Hudson, S Lloyd, DL Garne

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1 Learning medicine through a multi-disease framework KM Weston, JA Bushnell, JN Hudson, S Lloyd, DL Garne

2 Recognising multi-morbidity Future graduates face a world of multi-morbidity. Multiple chronic conditions/multimorbidity defined as multiple ( 2) chronic conditions Examples include arthritis, COPD, diabetes but also depression and other mental health issues including dementia. Ageing population.

3 Recognising multi-morbidity Managing the multi-morbid patient is an important skill. Medical schools worldwide are embracing the longitudinal-integrated-clerkship (LIC) model of medical education. How does the LIC give opportunities to recognise multi-morbidity?.

4 UOW MEDICAL DEGREE 4-year graduate-entry course Early and longitudinal clinical experience Includes a 12-month longitudinal community-based integrated clerkship in Phase 3 Phase 1 Phase 2 Phase 3 Phase 4 Year 1 Year 2 Year 3 Year 4 Phase 3: Extended integrated community placement in rural / regional primary and hospital care with electronic case based learning core 4

5 CLINICAL LOG ENTRIES 2010 cohort, entered Phase 3 in 2012 for 12 months blueprint list of 93 core clinical presentations 80 students recorded >21,000 episodes of care identifying >50,000 clinical problems 5

6 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Number of patient problems recorded per encounter 43% 55% =2 or more 24% 32% 1 2 > 3 Number of problems 6

7 Multi-morbidity examples Male, 65-74: 01. Fever; 37. Depression/Change in Mood; 49. Cough/Haemoptysis; 52. Wheeze Female, 25-44: 20. Trauma/Injuries; 35. Anxiety; 37. Depression/Change in Mood; 61. Abdominal Pain; 78. Pelvic Pain Male, 45-64: 04. Electrolyte Disturbance; 27. Tiredness; 61. Abdominal Pain; 66. Gastrointestinal Bleeding; 68. Vomiting/Anorexia/Nausea; 72. Urinary Retention; Other: Chronic pancreatitis Female, 75+: 10. Back Pain/Neck Injury; 87. The Elderly Patient; 89. The Patient with Chronic Disease; Other: Renal impairment

8 Clinical presentations accompanying ADDICTION n=384; 1.8% Number Percentage Depression/change in mood Anxiety Aggression/violence/abuse Self-harm Sleep disturbance Patient with chronic disease Hallucinations Tiredness Preventive health and screening Shortness of breath

9 Clinical presentations accompanying THE PATIENT WITH CHRONIC DISEASE n=1389; 6.4% Number Percentage Elderly Shortness of breath Abnormal blood sugar Joint pain/swelling Cough Weight change Depression/change in mood Back pain Change in bowel habit Indigenous patient

10 Multi-morbidity and continuity of care hypertension and hypercholesterolemia Over the past 12 months I have managed to counsel this patient regarding these preventative health measures and suggested the use of medications. On this visit I was able to show him that his cholesterol and BP were much improved. Over the course of the year we managed to significantly reduce his alcohol consumption, gain better control of his diabetes and managed to get him to have a colonoscopy, which was a massive task for him. 10

11 Recognising a hidden agenda Patient presented with sore throat but had a hidden agenda. Was evasive and moody but with some open ended questions I gained rapport and the story evolved. She has had past history of cutting and other self harming behaviour, has felt depressed for about 6 years and feels currently worthless, hopeless, has suicidal ideation and says that if she had a plan she would follow through with it. 11

12 The importance of doctor: patient relationship in multi-morbidity 65yo man presented reluctantly to the GP for a check-up, encouraged by his wife. He was obese, had hypertension, and was a heavy, long-time smoker.. I took his BP. Surprisingly, it was not too bad- 150/95. he has a very poor diet and has smoked a packet a day for 40 years. I realised how important rapport with a patient is - not only does it make for a better relationship between doctor and patient, it also affects the patient s treatment, as if they have a better relationship with you, they are more likely to listen to you. 12

13 Conclusion Health systems are largely focussed on singledisease; but this will need to change. Take-home message The LIC including its continuity-of-care principles offers students the opportunity to learn in a multirather than single-disease framework of medical education..

14 Questions

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