DIP Episode 228 - USMLE Nov 2020 Changes Series 1: Palliative Care 1

Okay, welcome. My name is Divine, I'm a resident. This is episode 228 of the Divine Intervention Podcast. And in this podcast I'm going to be introducing a new curriculum that is going to be in parts and hopefully should be completed pretty soon. It's what I call the Clean SP curriculum. So Clean SP curriculum. Basically it's just an acronym I kind of created to address some changes that are coming with the USMLE in like May 2020 especially for step one and Julio of 2020 for step two CK. So I'm just trying to you know prepare for that because we're essentially in April. So it's kind of coming on us pretty soon. But basically if you go on the USMLE website you look on the announcements actually post this on the 5th of November last year and a lot of people have been talking, talking the stuff up on Reddit. So I guess I figured I might as well make podcasts that will position people very well to tackle the vast majority of the questions they'll see on these topics. But basically the USMLE says that they will start including questions that assess system-based practices, patient safety, communication skills, legal and ethical skills and professionalism. And essentially they said for step one in May 2020 they will start having additional questions that assess communication skills. Then in June July 2020 step two CK will include additional questions on a systems-based practice, patient safety, legal, ethical issues and professionalism.

Apparently they're not going to be making any changes to step three. So these are things I'm going to focus on and in creating the podcast I'm going to try to cover most of the information that is specifically spelled out in the USMLE content outline. So I won't be going off the reservation here. I'll try to stick within the confines of the USMLE content outline. So hopefully you find this to be high yield and you find this to be helpful. If you have any feedback please do feel free to let me know. So what does clean SP stand for? The C stands for communications, the L stands for legal and ethical and then the S stands for the system-based practices and then the P stands for... So S is for systems-based practices and then the P is for professionalism. So you know kind of talk about those things across these series of our podcast. So let's just jump straight into it. So I think the first topic I want to go ahead and talk about is palliative care. Right? Palliative care. And the thing is before we actually talk about palliative care, one thing that's high yield to know for exams is to... is to kind of understand some key facts about death in the US. Right? So the thing is the leading cause of death because again the NV Me can make these epidemiology questions on the exam. The thing is the leading cause of death in the US, right? According to the CDC, the leading cause of death in the US is heart disease. But the thing is the incidence has been decreasing dramatically over time.

Right? The incidence of cardiovascular disease has been dropping. In fact, I suspect that a time will come where cancer will overtake heart disease as the most common cause of death in the US. Right? And also strokes, right? So the main output stroke, the main point is the word cerebrova, the 5 word for stroke, a stroke is a cerebrovascular disease. They may use that term on an NV Me, right? Again, the overall trend with those things are going down like cardiovascular disease, cerebrovascular disease, the incidence is coming down. So heart disease, number one cause of death in the US, number two is cancer. Right? Cancer is the second leading cause of death, right? And the thing is unfortunately, there's actually been an overall trend in the increase of cancer cases in this country. Right? And I mean, there's a lot of other things that have kind of been on the upswing. So you know, things like people dying from COPD, people dying from diabetes, you know, like metabolic diseases as they overall BMI of the population has gone up. All Alzheimer's, suicide, those things have all been on the upswing with regards to causing deaths. And one of the key statistic to know, right, this will fall for sure under the purview of systems based practices. The thing is, most health care spending in the US is actually on chronic disease, right? Most health care spending in the US is actually on chronic disease.

And a lot of the health care spending in the US goes towards like the last few years of a person's life, right? So these are all like systemic things like systemic problems that kind of go with with US healthcare. And the thing is, palliative care should not be something that you initiate, right? Like they could make this like a question where they put a series of statements and then you have to pick out which one is correct. The thing is palliative care. You should actually not think of it as like care for the dying. Even if he has, that's a big focus. But the thing is, if any patient has a chronic disease, very high yield to notice, if any patient has a chronic disease, you should consider palliative care to be part of like comprehensive care for those folks, right? And one good trend that has been happening in US healthcare is that patients with terminal disease, like most of few, like there's fewer and fewer patients with terminal disease dying in the hospital. Most of them are now dying outside the hospital, right? So that means more people are beginning to embrace palliative care, right? So like more people are dying at home, more people are dying in the hospice. But one trend, again, this will fall under the purview of systems, peace practices is that there is more people being admitted to the ICU, like being hospitalized in the final few days, like the last 30, 60 days of life, right? That's kind of like a disturbing trend.

There's like more admissions to the ICU, more hospitalizations during those periods. And the thing is the specific number that they sickness that all this person has a terminal illness is if there's the expectation, right? There's the reasonable medical expectation that this person will likely not survive beyond the next six months, right? And the thing is, and I mean, in the next podcast, because this is just more of like an intro podcast. So I really do want to keep this short of the, I want to kind of talk about some things that are pregnant to the communication skills aspect of this clean SP curriculum that again, the MBM is kind of like going after studying in studying essentially next month. But basically, you want to, because people that are undergoing terminal illness, they tend to have depression. And one high you'll think to know is that the pH Q nine questionnaire is very well validated, very good for screening for depression. And then for generalize anxiety disorder, again, you can use the got seven questionnaire, right? The generalize anxiety disorder seven questionnaire. That's something you can use, right? And the thing is, before I jump into the communication stands, again, some other key principles of palliative care, right? Again, you want to avoid invasive tests, you even want to avoid painful physical exams in a person's last period of life, right?

And the thing is for the most part, palliative care really does focus on like managing a patient symptoms, focuses on advanced care planning, focuses on like, you know, making the process of death as pleasant as possible. Even if death is not really a pleasant thing, but you can make it less unfavorable, less put it that way, right? With palliative care. And again, the thing is palliative care for patient has like chronic illness, has like serious illness, you want to initiate palliative care sooner rather than later, right? And the thing is one key fundamental principle of palliative care is also like having goals of care discussions on a regular basis, right? You want to have these schools of care discussions on a regular basis. Now, what if the MBA me gives you a question and they say, um, which of the following at the biggest risk factors, right? You know, they may give you like a bunch of things in a long ask questions, them, and then they'll say, which of the following at the two biggest risk factors for failure to initiate advanced care planning discussions? The things you want to think about are one, just the fear of bringing the topic up, right? People don't like bring because it's like, oh, you're talking about death in a healthcare setting, right? So one is bringing the topic up and another big risk factor is also like keeping the discussion so sent, right?

Because the thing is physicians have the fear, especially with the way health cares in this country where like you have to do things really quickly. You have a only maybe like 15 minutes per patient because of insurance or reimbursement or school bolts. The thing is essentially, um, people are free that way. If they start this advanced care plan discussion, the patient will have so many questions and I won't have time to get through all I need to get through in the patient encounter. So those are the two, those are the two big risk factors. Now, the thing is in terms of communication skills, right? Like, you want to know the process, want to know the process of discussing the process of discussing visa, advance having these advanced care planning and discussions, right? The thing is many of these things kind of follow a general principle where you start open ended and then you go close then that at the end. I mean, this is a principle I teach people that I took her for step two CS. We want to start open open ended, right? With general questions, right? And then after that, you then start going into the weeks. That's just a useful principle for most, in fact, that's a concept. I want you to keep at the back of your mind when you're approaching NV Me questions that deal with communications. If an open ended question has not been utilising the queue system, pick an answer choice that involves using an open ended question.

If an open ended question has been utilising the queue system, then you can start veering into the realm of close ended questions, right? So the thing is, in general, you want to say like, oh, you know, you don't want to start with like, oh, this is something that this is a discussion I have with all my patients. And you know, you kind of again, make it about the patient, you tell them that, oh, you're initiating this discussion with them because you want them to have a scene, they are care, that you don't want other people to be the ones that are making decisions for them in the end that, you know, you want them to have a say, you want to maintain their autonomy, right? You want them to maintain their autonomy in their care, even if they becoming capacitive it in a way where they may not necessarily be able to communicate their decisions. And the thing is again, a key principle is when you're talking about these things, always start from the most like the biggest thing, right? Like, or let's say the patient becomes unconscious, like they're going to like a persistent vegetative state, that's how you know, like if a patient goes unconscious, like, you know, kind of start like, oh, what would you want us to do on that circumstances? And then after that, you can then begin to, you know, after you've kind of cleared out the big things, like, if your heart were to stop, or if you were to stop breathing, you also put a tube down your throat, you handle those big things first.

And then after that you can then begin to go into the weeds like, do you want blood transfusions? Do you want nutrition? Do you want this? Do you want to get nutrition through an IV and stuff like that? Right? Those are again, high old ways to kind of go through these discussions. Now, one high you, this one I'm certain, again, just from going going through the USMLE content outline, this is something they definitely care about. The thing is on NVM is you need to know how to break bad news to a patient. It's very important. You need to know how to break bad news to a patient. And the thing is the mantra that you should use because I, I can almost predict that when we start writing these questions, they are going to start using nomonics that go with these communication mantras on these exams, right? You need to pick it out. Like, that's why you see for depression, I said, oh, PHQ9 is the buzzword you want to remember for generalizing anxiety disorder, the gut seven nomonic is something you want to remember for sharing bad news, one of the one you want to remember is called peace spikes, right? Many of you have the thing is these communication skills, whatever's these are things that you probably learned like in your introduction to clinical medicine course or whatever. But you know, most of those things have kind of floated out of a person's brain. So, you know, these podcasts will hopefully help you bring that back. But yeah, there's the peace spikes mantra, right?

And I'll kind of give you like what peace spikes means. And then I'll kind of give you examples of these things. Right? So the P stands for like preparing for the discussion. Before you go into the patients room, be prepared, right? Because the thing is usually when these discussions are held and the presence of many family members, if you're not prepared, you won't be able to answer the questions with with with confidence, right? So you want to be prepared because it's almost like hocks are going to be picking at you or you're in the right, because they're going to have a lot, a lot of questions. So prepare for the discussion. And then the S means setting up the environment, right? So you want to set up a good environment, you want to place where there's privacy, you want to be a being a place where like there's no like beepers or whatever that's going to disturb the patients, usually it's good to do this like in a separate room apart from like the ICU or something. And then the the next P means like finding out what the patient, right? What the patient, you know, unlike the family on the stand, it's usually good to it's usually good for you to kind of assess the persons on the standing of things. And the thing is the munch, this peace spikes mantra, believe it or not, this thing has already is already being tested on NV Me exams, right? So they usually write these as ethics questions and see what's the next step or something.

And they will give you all these series of statements and you need to pick one that agrees with these mantra. Essentially, if a part of this algorithm has been done, then you don't pick that answer, you then go to the next thing on this algorithm. So again, peace for preparation, the S is for setting again, set up a good environment, private environment, the P means preparing, like assessing what the patient and so the peaceful patient are in the family understand. And then the I is like information, right? So essentially, you essentially want to ask them how much do you want to know, how much do you want to know, right? And then the key means the knowledge, right? So you go ahead and provide the knowledge, right? The key for knowledge, you provide that bad news, right? That that that you're kind of talking about. And then the ease for like emotional responses, right? So you know, kind of like respond to the patients emotions because again, bad news, we're almost to hear bad news, right? So you know, kind of a big thing there. And then the S means sharing, right? So like next steps, you share your next steps, like because the thing is when you give people bad news, one thing that almost comforts, and again, I've had this experience because I have done I see a rotation in my intern year. I mean, I did not have done I did I see a rotation in my intern year, no longer in intern anymore.

But basically, right, families always respond very positively if at the end, you have like a defined plan of care, right? So share those plans, don't keep them in the dark so that they are not like kind of like left, because the thing is when you have these discussions, right? It's almost like the bottom has fallen out of the world, right? When you provide a plan, it's almost like you're replacing a bottom into that world, right? So that's a very high yield thing. Again, high yield, just good thing to do, just in clinical practice and high yield thing to know, for example, right? So again, the peace fight, right? The preparation part again, you kind of want to know what you're talking about, you don't want to like, see what I'm just going to win this family discussion. And then let's say you don't know the patient's pregnant medical history, you don't know the diagnosis from pathology, you don't you've not reviewed the imaging muffin, that's not a pretty idea. Again, you want to be prepared, right? And then like the setting, again, like I said, again, go to a place where and usually it's good to bring like the part of the nursing team for these discussions, bring like a social worker for these conversations, right? And again, bring the box of tissues because you know, there's going to be tears at these things. And then again, the next piece like again, like again, like assess what the patient and family understand, like, oh, would you understand about what's going on?

Again, these are sentences that your friends at the MBME can write on these exams, right? Like, would you understand about what's going on? Would you understand about this sickness that you have? What have other healthcare practitioners told you about your illness? What you think is going to happen, right? Just as then these kinds of questions, you know, it's kind of preparing. And then the I for information, right? Again, you just ask them like, how much do you want to know, right? Would you like me to tell you the details? What do you like me to talk about? What I know it's a lot to come across, but what would you want me to focus on? Right? And then the case for knowledge, right? And the thing is you don't just like just dump the knowledge on the patient, don't just tell them, boom, or you have this, you're going to die at this blah blah, no, right? You have to use like an empathic statement, right? You see things like, oh, I feel bad that I have to tell you this or, unfortunately, this imaging test we did or this biopsy we did show this, I'm afraid this news is not very great. You know, you kind of in have some interest statements, kind of preparing them for the inevitable, right? And then the E, right? Again, like empathy, right? I don't think I mentioned this one. I mentioned, I think I did speak speaks, I speak, speaks to the E, the East ends for empathy, right? So the thing is again, like acknowledge the families emotions, right?

You know, give them time to respond, don't just keep talking, talking, talking, talking, no, right? You should have like a pause. This is something high yield, actually to do for step two CS, when the patients that's creating something have a pause, right? Hold your hands, have a pause. That tells them that you're acknowledging your emotions, right? You know, kind of give them time to respond, tell the patient that you're there for them, you're not gonna abandon them, right? Again, I know this must be hard information for you to hear, tell me how you're feeling, I'll do whatever I can to support you stuff like that, right? And again, the S, right? Again, where you kind of share your summer rights, I mean, you kind of talk about next steps, right? You kind of talk about the next steps. Again, these are just I all high yield things to know with regards to sharing a bad news. And with regards to advanced directives, right? So there are actually two types of advanced directives. So this is me going into the more formal part of things now, right? So the advanced directives, right? So the first one is a living well, right? Living a living will is essentially like literally like something that a person does while they're like, you know, like coherent and everything. And you know, you essentially in a living will you give like very specific directions, very specific decisions that could direct like the care of a patient, right? Like what should happen in different scenarios?

What kinds of interventions can be done? Can they get into baited? Can they get nutrition through an IV and all those things? Those things are clearly spelled out in a living will. Now, the second thing is a second kind of advanced directives, a healthcare proxy, right? This is something that's also known as a durable power of attorney on MBM Es, right? Essentially, this is a person that the patient designates to make healthcare decisions. And the thing is you can use either a living will or you can use a healthcare proxy or you can use both. But it's very high you to know for exams again, with all these things that the MBME put in the content outline, it's very high you to know for exams that if you're using both, you need to indicate that oh, you know, if let's say the healthcare like the living will says this and the healthcare proxy says this, you need to decide as the patient, which one will take precedence if both if both of those advanced get directive modalities clash with each other, right? That's a very high yield important thing to know. So since I'm coming up on 20 minutes, I think I'm going to go ahead and pause here. Again, as I do at the end of every podcast, I go for one or one tutoring for many exams. Step one, step two, CK step two, CS step three, pre-clean cool med school exams, 30-ish of exams, ITER medicine, if you're medicine resident or a peach resident for like the entering exam, the board exams for those specialties I tutor for those.

I offer 20 hour booster courses for step one, step two, CK and step three. Again, I review the most notes for those exams in a Q&A format. There's a lot of clinical vignettes and I integrate across multiple disciplines. Those are those things tend to be pretty good at picking out people's weaknesses and turning them into strengths. And then I also do like this longitudinal tutoring where again, if you're studying out med school as a you know fresh first year or studying out 30 as a fresh like 30-amid student, I tutor you for all you like your block exams or your shelf exams and as I'm doing that I'm leaning a solid base of like a solid foundation with regards to knowledge and test taking strategy as I take you through those things. And then if you met student applying to residences or like an ERAS app or a college student applying to med school so like an AMCA app, again I offer like consulting and coaching for these things like rec letters, personal statements, editing applications, mock interviews for many different specialties.

The vast majority of people I've worked with have all pretty much all much that you had the first choices and again I've helped people with tricky applications like low scores, graduated from med school 10 years ago, I've worked with many people that have had tricky applications or circumstances like no research or whatever right and they've matched right so if these are conditions you'll face you know just kind of let me know and please don't forget to subscribe to the podcast. It's an Apple podcast on Spotify, it's on Google Play and I also have the Word Press website please subscribe and then thank you for all those that are subscribing to the You Tube channel please subscribe as well. It's called a Divine Intervention USMD Podcast and Videos and if you have a college buddy that is here for like any of the MCAT subjects I tutor for all those things or even most college primates subjects I tutor for those things. And then my life lesson for today is to just be patient right be patient right. The thing is many people right they want to get things immediately right. I feel like in this current world we live in a kind of like a drive-through mentality right where we want something right now we want something immediately but one thing I've noticed is whenever you repitioned you tend to get the best but if you kind of rush things you tend to get second-fiddle right you get less than what is best right.

So the thing is that it's important as the Bible says right be long-suffering be patient right be gentle be patient patience is a very important skill like literally patience is a virtue patience is a virtue. A person that is patient again will typically assess a situation and essentially almost always make the right decision amongst many competing decisions that will lead to very delicious circumstances. So again be patient patience is a virtue like when you're patient you tend to make higher quality decisions. So thank you for listening to the podcast. God bless you. I'll see you next time. Thank you.

Communications, Legal and Ethical, System-based Practices, and Professionalism.

Heart disease (Cardiovascular disease).

The fear of bringing up the topic of death, and time constraints/keeping the discussion too short.

SPIKES (Preparation, Setting, Patient Assessment, Information, Knowledge/Empathy, Sharing next steps).

Comprehensive care and symptom management for patients with chronic or serious illnesses, not just those who are actively dying.

The GAD-7 questionnaire.

Which directive takes precedence.

SPIKES (Preparation, Setting, Patient Assessment, Information, Knowledge/Empathy, Sharing next steps).

To provide specific written directions for care while the patient is still coherent.

Preparation (The physician must be thoroughly prepared and knowledgeable about the patient's history).

PHQ-9 questionnaire.

The "big things" (e.g., unconsciousness, cardiac arrest) must be addressed before moving to specific interventions (IV nutrition, blood transfusions).

It should be initiated early in the course of a chronic or serious illness, not just at end-of-life.

SPIKES (Preparation, Setting, Patient Assessment, Information, Knowledge/Empathy, Sharing next steps).

To provide specific written directions for care while the patient is still coherent.

Preparation (The physician must be thoroughly prepared and knowledgeable about the patient's history).

PHQ-9 questionnaire.

The "big things" (e.g., unconsciousness, cardiac arrest) must be addressed before moving to specific interventions (IV nutrition, blood transfusions).

It should be initiated early in the course of a chronic or serious illness, not just at end-of-life.