Goal-oriented case presentation for GP trainee education

Koki Kato (left) is the director at a GP practice in Fukuoka, Japan, and the deputy director at the Academic and Research Centre, Hokkaido Centre for Family Medicine, Hokkaido, Japan. He is on Twitter: @kokikatokk

Junichiro Miyachi (right) is a GP trainer at Azai-Higashi Family Clinic in Shiga, Japan, and the director of the Fellowship Course, Hokkaido Centre for Family Medicine, Hokkaido, Japan.

As GP trainers, my colleague and I regularly supervise medical students and postgraduate year one and two physicians. They need to learn the patient-centred viewpoint in the GP rotation.¹ However, it is not easy for them to attain such a viewpoint.

They attain a strong disease-focused view in medical school. They learn a problem-oriented medical system² and give oral case presentations³ aligned with the system. As a result, the case presentations based on the problem-oriented system can function as a medium through which medical students gain a disease-focused viewpoint.⁴

Although a disease-specific system works well for otherwise healthy patients with few diseases, it could not suit elderly patients with multimorbidity or severe disability.⁵ General practitioners see many such patients categorised into the latter and need to see patients in another way. Patients with multimorbidity usually have conflicting disease-specific treatment targets. We need to care for our patients in the context of patients’ perspectives, functions and goals, considering the trade-offs.

How can we GP trainers defy the disease-focused view of trainees? One of the keys would be deliberately changing our language from a disease-focused system to a goal-oriented one⁶ when educating our learners. In goal-oriented care, health care providers focus on individual specific care goals, not problems. For example, the problem of a patient with knee osteoarthritis would be the “knee osteoarthritis” and resulting “pain”. However, the patient’s goal might be “walking around with her grandchildren”, which has a high value on her well-being.⁷

We need to be careful with our language like this: “This patient is a 70-year-old female with knee osteoarthritis and uses acetaminophen for her knee pain“. Instead, you might want to use a presentation like the following: “Elisa has two grandchildren, and one of her goals is to walk around with them. However, her knee pain due to osteoarthritis is unable her to do that. How can we support her?“.

As Mother Teresa said, we should be careful of our words, for our words become our deeds and might affect trainees’ way of thinking. For example, if GP trainers use problem-oriented presentation, it will fix trainees’ perspectives on disease treatment without considering patients’ goals. On the other hand, using goal-oriented case presentations may develop trainees’ patient-centred views.

References

1. Kato K. Family medicine viewpoint: seeing patients in the context of their lives [published online ahead of print, 2021 Jul 29]. Fam Pract. 2021;cmab090. doi:10.1093/fampra/cmab090
2. Walker HK. The Problem-Oriented Medical System. JAMA. 1976;236(21):2397–2398. doi:10.1001/jama.1976.03270220017024
3. Melvin L, Cavalcanti RB. The Oral Case Presentation: A Key Tool for Assessment and Teaching in Competency-Based Medical Education. JAMA. 2016;316(21):2187–2188. doi:10.1001/jama.2016.16415
4. Holmes, Seth M., and Maya Ponte. En-case-ing the patient: disciplining uncertainty in medical student patient presentations. Culture, Medicine, and Psychiatry. 2011;35(2):163-182. doi: 10.1007/s11013-011-9213-3.
5. Tinetti ME, Bogardus ST Jr, Agostini JV. Potential pitfalls of disease-specific guidelines for patients with multiple conditions. N Engl J Med. 2004;351(27):2870-2874. doi:10.1056/NEJMsb042458
6. Reuben DB, Tinetti ME. Goal-oriented patient care–an alternative health outcomes paradigm. N Engl J Med. 2012;366(9):777-779. doi:10.1056/NEJMp1113631
7. Kato K. Wellbeing is the key. Br J Gen Pract. 2021;71(709):346. doi:10.3399/bjgp21X716513

 

Featured image by Brett Jordan at Unsplash