“Working with uncertainty in co-morbidity”

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 case:“Even though I have problems and I know you can`t help me I`m 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 patient’s life (living conditions, contacts with family, friends and neighbours) • Exploration of patient’s long & short term expectations, fears • Exploration of options in management of patient’s physical condition (social wellfare resources, nursing home, medical assistance, government support, charity assotiations…) • Agreement with patient for the future plan