Session 5
This section contains all of the suggested discussion questions for class meetings.
    (5’) Welcome Back
        Students share any updates for the class; any comments lingering from the last session
        Introduce the role-play exercise to students. *Note at UNC SOM, students shared that they would have preferred spending a longer amount of time doing the role-play exercises versus discussions.
    (50’) Role-play
        There are two scenarios included in the activity. Put students into “Break Out” Rooms - ideally in groups of 3-4.
          Groups of 4: Each pair role plays a scenario; the other pair observes and comments. Pairs switch.
          Groups of 3: One person observes; two people get to role-play and then everyone rotates roles.
    (5’) Debrief (or you can work the debrief into the discussion on the modules)
      Questions to ask:
        How challenging (or not) was it to have those conversations?
        What strategies did you employ to discuss financial toxicity?
        Were you able to ask screening questions successfully?
        If patients had challenges understanding you, how did you switch up your communication technique?
        What was your feedback, from the observer and from your patient?
*(10') Break*
    (25’) Discussion on Module 6
      This module explores how medication non-adherence can impact health, reasons why patients typically do not adhere to prescribed treatment regimens (especially due to costs), and strategies for high-value prescribing, which aims to reduce medication cost and complexity to improve patient outcomes.
        What are the individual and societal harms associated with medication non-adherence?
          This module discusses patients putting off needed care and/or other household needs (such as groceries) due to medication costs. For example, when patients cannot afford their medications, they often stop taking some of their medications or they resort to other behaviors that undercut the benefits of medication, such as skipping doses, splitting pills, delaying refills, and avoiding new prescriptions. This contributes to delayed diagnoses and inadequately managed chronic diseases, which increase the burden physically and financially for patients, as well as society as a whole.
          From Module 6: “cost-related medication nonadherence is a common problem that leads to more frequent emergency department visits, psychiatric admissions, and nursing home placements, as well as decreased overall health status.”
        What are the barriers to discussing medication costs with patients?
          Examples include: time, taboo topic, strength of patient rapport (i.e., is this a new patient? Is this a patient you've seen before?), patient trust.
        Is it important that prescribers integrate questions regarding ability to afford medication when discussing treatment plans?
          From module 6: The majority of patients say that they would prefer to discuss the costs of medical treatments with their physicians ahead of time. Seventy-nine percent of physicians say they wished they could discuss costs but don’t due to time constraints and unease with the topic.
          “More expensive medications often result in lower daily compliance rates (patients take the medication less consistently), which for certain medications results in worse patient outcomes. For example, in a study of more than 90,000 people taking statins, those who were prescribed generic statins had a better compliance rate, which results in an 8% reduction in incidence of death and hospitalization for ACS or stroke in that group.”
          According to one study, when physicians and patients discussed costs, 41% of patients were switched to a lower cost medication (vs. only 12% of those patients who did not discuss costs of medication with their physicians.
        According to Costs of Care, what are some screening questions you can ask?
          When you take the medication history, ask patients:
            Do your medications cost too much?
            Have you ever cut back on medications because of cost?
            Have you ever cut back on other things (e.g., food or leisure) due to high drug costs?
        What is the definition of high-value prescribing (as used in the module)? What is an example of a medication that is frequently prescribed inpatient but is often unnecessary when the patient is discharged? (PPIs for stress ulcer prophylaxis)
          “High-value prescribing entails providing the simplest medication regimen that minimizes physical and financial risk to the patient while achieving the best outcome.”
          High-value prescribing is achieved by: 1) decreased costs; 2) decreasing complexity; or 3) decreasing risk of medications; ideally we aim to decrease all three simultaneously.
        What are the most effective strategies in lowering drug costs for patients? Have students talk through the GOT MeDS mnemonic.
          “GOT MeDS” mnemonic:
        At the end of Module 6, you helped lower the medication costs for a hypothetical patient. You also practiced in the activity posted on Sakai. Could you see yourself using these same strategies in your practice? Why or why not?
          Call on students to share what they found in the Module 6 Section 9 Rx lowering activity and the Rx lowering activity that we created.
    (25’) Discussion on Module 7
      This module explores the pitfalls that can occur in clinician-patient communication and techniques for improving communication. Learners explore models of communication, including Cleveland Clinic’s communication program.
      We'd like to get an understanding for how helpful you found this module about communication. Was it eye-opening? Are the recommendations helpful?
        Medical school teaches us the value of iteration - repeating and relearning over and over again. That is why we think this module is particularly important. But if you were designing this course or if you were to redo these modules, at what point would you think this training to be useful?
          Is it helpful to have these reminders every once in a while?
        Students should share examples of both good and bad physician-physician and physician-APP communication.
      What seem to be the most common pitfalls in clinician-patient communication?
        Note: The Story from the Frontlines video in Section 2 and the podcast in section 3 feature Dr. David Ring and Dr. Maggie Lowenstein discussing pitfalls: “Conversations about value constitute some of the most challenging discussions we have,” Dr. Maggie Lowenstein wrote in an article for JAMA Internal Medicine (as read in module 7, section 3). “Part of the struggle comes from explaining complex concepts such as the harms of overdiagnosis and overtreatment. However, the truly difficult task is breaking the news that medicine is imperfect, and we don’t have answers to every question. As a young physician, I work hard every day to gain patients’ trust. I worry that admitting the fallibility of my profession will be conflated with inexperience, my hard-earned trust will be lost, or worst of all, my patients will feel that I have abandoned or failed them.”
      What is a communication skill or tactic that you took away from this training that you would like to try with your patients? Discuss takeaways from Costs of Care, too.
        The module provided the following tips for effective communication:
          Begin with active, empathetic listening;
          Get to know a few things that make that person special;
          Elicit patient beliefs and questions;
          Summarize and legitimize their concerns;
          Use non-technical language and pause for questions between points;
          Focus on creating a partnership;
          Have “scripts” for common scenarios, e.g.: patients seeking antibiotics, patients with limited life expectancy, and patients with pain seeking pain meds.
        Module 7, Section 4 also includes a table of common words/phrases that are used in medicine (such as “patient refused”), potential pitfalls (e.g., “Establishes decision- making divide (subtle or overt) between patient and clinicians”), and proposed alternatives (e.g., “Patient declined,” or “Patient preferred not to/would rather not.”)
      Would you be willing to try writing “SOAP-V” notes during your rotations? Why or why not?
        Might be an opportunity for clinical students to share their experiences writing notes for their preceptors. Did they think they had enough experience to really comment on the value of the care?
        If you have preceptors/professors helping to facilitate, ask their opinion of the SOAP-V.
      Review the tools discussed in “Section 7: Partnering with Patients.” What do you think is the most effective way to help patients to be partners in their treatments?
    (5') Wrap-up
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