Structured Group Reflection and Improvisation Developing skills for

Structured Group Reflection and Improvisation: Developing skills for the medical home in a variety of cultural settings Daisuke Yamashita MD 1, Kenichi Yokobayashi MD 2, Morito Kise MD 3, Yasuki Fujinuma, MD 2, Randall Longenecker, MD 4 1. OHSU Family Medicine 2. HCA-JCCU Family Medicine Residency Program Tokyo 3. Kawasaki Municipal Tama Hospital Family Medicine Residency 4. The Ohio State University Rural Program Background: The Patient-Centered Medical home (PCMH) requires special competence in addressing the following: 1. Uncertainty – unique and surprising clinical cases are not strictly biomedical. 2. Complexity – multiple relationships with multiple layers of sociopsychological meaning challenge even the experts among us. Training in uncertainty and complex bio-sociopsychological problems is essential to implementing a PCMH. Implement in practice Take away a pearl Inter-textual reflection HCA-JCCU Family Medicine Residency Program Tokyo Dr. Yasuki Fujinuma, Dr. Kenichi Yokobayashi Setting: Based in Tokyo, Japan. Total of 11 residents with 10 faculties. Network of 6 urban clinics. Emphasis on home care and geriatric care. Name: "Clinical Jazz" When: Once a month at the residency conference. Time: 30 minutes x 2 cases Who: Residents and Faculty Diffusion of an innovation 1998 Shaughnessy AF, Slawson DC, Becker L. Clinical jazz: Harmonizing clinical experience and evidence-based medicine. J Fam Pract 1998; 47: 425 -8. 1999 Birth of “Clinical Jazz” as introduced by Dr. Longenecker at Mad River Family Practice in Ohio. 2005 April Dr. Fujinuma found Dr. Longenecker’s presentation on internet. 2005 May Dr. Yamashita met Dr. Longenecker at an STFM conference in San Francisco The Ohio State University Rural Program Dr. Randall Longenecker Setting: Mad River Family Practice, West Liberty, Ohio. A “ 2 -2 -2” integrated rural training track residency Name: “Clinical Jazz” and “Faculty Jam” When: Weekly, on Thursdays Time: 75 minutes, single case Who: Residents, Faculty (including residency coordinator and clinical psycologist), and visiting students or other guests (“Faculty Jam” is for faculty only) Bring a case & a question Discussion: “Clinical Jazz” was successfully implemented among four different residencies in different clinical and cultural settings. "Clinical Jazz" promotes relationship centered medicine, reflective practice and balancing evidence and experience in different cultural contexts and provides a safe “educational home” for difficult cases This suggests that "Clinical Jazz“ may be useful in a patient centered medical home, dealing with cases of great complexity and uncertainty. Clarify the question Refine the question “Clinical Jazz” A semi structured small group process designed to promote reflection and develop skills working in a complex, relationship-rich environment. 1. Pick an emotionally moving case, prompting surprise, sadness or confusion. (self reflection) 2. Draw a Genogram (relationship centered) 3. Open discussion with group. Everybody participate! EBM and experiences are woven in the discussion. 4. Conclude with a “clinical pearl” 5. Reflect on the case and proceed to practice Challenges: 1. Requires experienced facilitator to lead discussion. -Discussion may become scattered and unfocused. -A facilitator can avoid this by keeping the group focused on the original question. 2. Difficulty formulating clinical pearls, i. e. taking the “action turn” -Requires everyone’s participation to come up with pearls; forces improvisation -Improves over time as group becomes used to this process. 3. Difficulty finding evidence in literature. Dr. Morito Kise Based in Kawasaki, Japan. City next to Tokyo. The clinic is part of 300 -bed community hospital. Total of 7 residents. Emphasis on inpatient, pediatrics and emergency care. Title: “Clinical Jazz” When: twice a month Time: 60 min, single case Who: Residents and Faculties. Kawasaki Municipal Tama Hospital Family Medicine Residency 2006 April “Clinical Jazz” was adapted to the residency in Tokyo (Dr. Fujinuma and Dr. Yokobayashi) 2006 April “Clinical Jazz” was adapted to the residency in Kawasaki (Dr. Kise) 2006 July Dr. Yamashita moved to OHSU, Portland Oregon for residency. 2007 March Dr. Fujinuma and Dr. Yokobayashi received “Best Teaching Pearl Award” at 15 th Japan Society of General Medicine annual conference. 2008 July “Clinical Jazz” was adapted to OHSU Family Medicine South Waterfront clinic (Dr. Yamashita) Dr. Daisuke Yamashita OHSU Family Medicine South Waterfront Clinic Based in Portland Oregon. In large academic medical center. Part of OHSU FM residency. Total of 12 residents in this clinic. Urban setting and patients with diverse ethic background. Name: “Difficult Case Conference” When: Once a month at the clinic Time: 30 minutes x 2 cases Who: Residents, faculties and a clinical psychologist OHSU Family Medicine Next steps: -Share "Clinical Pearls" among residencies. -Develop evaluation tools to measure the effectiveness of "Clinical Jazz" in promoting reflective practice. -Evaluate the impact upon patient care -Incorporate other clinical staff in the setting of a patient centered medical home, further promoting team-based care. Daisuke Yamashita M. D. Kenichi Yokobayashi M. D. Contacts: yamashid@ohsu. edu yokobayashi@hotmail. co. jp