Thank you, Sarah. It's always a pleasure to work with you, and I'm also quite thrilled about our turnout. As Sarah said, we've set another record for attendance, and I know it makes all of our faculty members very happy. We really enjoy this course. In fact, of all the lectures and courses I've done over the years, this is hands down my favorite due to a combination of the audience and the audience really desire and enthusiasm for this course. As well as the faculty members, I am pleasured and honored to work with. We'll start off today's course with foundational talks on gastroenterology and endoscopy practice and build on those talks over the next two days. It's my pleasure to start us off by addressing both the art and science of a quality patient visit. I do not have any disclosures, and we'll start off with a couple polling questions. Which of the following are essential components of the art of patient care? And we'll give everybody a few moments to answer, and then Eden will tally things up for us and let us know how we did. They are correct. And as we'll see in a few moments, these are really the pillars of the art of patient care. Patient experience and patient satisfaction are different descriptions of the same process, true or false. Actually, the answer is false, as you'll see in a moment. They are not the same. They are not different descriptions of the same process. They are different descriptions of a different process. So, our objectives for today, I want to spend the first part of the talk discussing the art of a quality patient visit. This has traditionally been described as bedside manner, and I still think it's great to describe it that way. I like to really view it as the provider-patient experience. This really tells me how are we doing as providers as it relates to being a patient advocate, to caring, to speaking respectfully to the patient, and as you'll see, a number of other things. And then combine these objectives at the end by focusing on the science of a quality patient visit, and I really focus on what I think are the two most important parts of the consultation or follow-up, and that is the history of present illness, or that subjective first section, and then the impression and plan, specifically within the impression, the differential diagnosis. So, if we, as providers, combine these two entities, the art of a quality patient visit and the science, and combine them well, I believe it's your time and our time as providers to shine. Shine when you present your consultation to your collaborating physician, shine when referring physicians and referring providers are reading your notes, and most importantly, shine in the eyes of the patient that you come off as a true patient advocate. We're here for one reason, and that is to deliver high-quality care to our patients, and it starts with a quality patient visit. So, let's start with a few definitions. Patient interaction. Patient interaction is the total of all interactions that patients have with a healthcare entity that influences their perceptions and outcomes of care. Remember that perception sometimes is reality, so it's important that we are clear in all aspects of our communication with our patients. Now, there are some parts of this interaction that you cannot directly control, meaning when patients interact with the front desk, when they interact with scheduling, but you as the provider really have the most impact on the direct influence of what a patient thinks about their interaction, and as you'll see in the next slide, their experience. Next slide is patient satisfaction, and that's very simple. Our patient's expectation of the patient achieved, and as you'll see later, patients have expectations, and they are very simple, and they simply want to know whether these expectations are achieved with the visit. So, let's look at the foundation of the art of a quality patient visit. I like to think of these as the four pillars of a quality patient visit, and that's caring and advocacy, listening, which is different than hearing, explaining, and teamwork. So, let's start with caring and advocacy. With every patient visit, make sure you introduce yourself. Even if you've seen the patient two or three times a year, always introduce yourself. For example, hello, my name is Dr. Vicari. I'm the gastroenterologist here at Rockford Gastroenterology today. What brings you to see me? At that point, it's really important for a hard stop. You've made your introduction. You've asked them why they're here. It's now the patient's time, and I think we have to keep that in mind. This visit is about the patient and about the time the patient needs to get their message across to develop a good plan. So, at this point, stop talking, start listening, and we'll talk more about listening in a moment. When the patient is done speaking, telling their story, and you start to speak, make sure you maintain eye contact with the patient when speaking. It shows you're focused. It shows with body language you're listening, and it shows you care. Another nice little trick to start to show you care when you're being the patient advocate is once you're done with asking medical questions, ask some non-medical questions about the patient. As you're listening to the patient when they speak to you, perhaps there's something they say that may allow you to speak about something that's non-medical. Perhaps they're wearing a shirt or a jacket that says a place they visited. Perhaps they're there with a family member, and that might be your intro to start to talk about something personal about the patient. There's some very nice survey studies that show when we do that as providers, if we spend about a minute or a minute and a half talking to the patient about something private, for example, Oh, Eden, I see you're here to visit me today, and you've got, sorry, something has popped up on the screen, and Terrence, I'm not sure what that is. Thank you, Terrence. And I see you've got a shirt that you've been to Montana. I've been to Montana, too. It's a great place to visit. Tell me what you like about Montana, something like that. If you spend about a minute or a minute and a half talking about the patient at a personal level, when they're asked in surveys how long the doctor spent or the PA or the NP spent asking questions about you and your personal life, typically their answer is four or five minutes. So just a small amount of time makes a huge impact on the patient, and they kind of exaggerate the time that you spent talking about their personal life, and you begin to make that personal connection. A big point, and we've seen this also from survey studies, it's always important to focus on the patient, obviously, but in this day and age when some of us are using the computer in the office with the patient visit, it's really important to try to avoid putting the computer between you and the patient. If you look even across age demographic lines, pretty much all age groups do not like it when their computer is between you and the patient. It kind of puts up a barrier and maybe says that you're focusing more on the computer than you are on the patient. Use words the patient understands. We have to know our patients. You have to individualize each patient's medical literacy. Don't talk above someone whose medical literacy may be low, and those who have more advanced medical literacy, don't oversimplify things for them. So know their medical literacy when you are speaking to the patient. Be nice, show empathy, show compassion. It's very easy to do. Never show you're in a rush. Speak slowly, speak softly, and show that empathy that you have as a provider. We never argue. Even when you're right and the patient is wrong, never argue. Find a better way to explain the situation and work through the difference, and of course, never judge. I'm a big advocate of body language. I think body language speaks much louder than words most of the time because most of the time when we are unhappy or get angry, our body language almost has a mind of its own. So control your body language and use it to your advantage. For example, sit at the same level of the patient or slightly lower. When we are above the patient or looking down at the patient, that's a bit of a power move. It's kind of a power position, which doesn't necessarily make the patient feel relaxed and confident, and it also might show some slight disrespect. So sit at the same level or slightly lower than the patient. It helps put them at ease. Don't cross your arms. That's kind of another power position. Patients might interpret that in a wrong way. Maintain a relaxed body position. And to an appropriate level, don't be afraid to lean in slightly or even move a little closer to the patient. Obviously, keep a respectful distance, but let your body language speak loudly. When speaking, especially when speaking about some more difficult topics, nod, smile, show that affirmation. Smiling really helps. Patients really like when we smile. It puts them at ease. It helps them build confidence in you. So body language, body language, body language speaks very loud and very important. Okay, let's move on to listening. Remember that hearing and listening are two different things. When we listen, we are focused. So listen, listen, and when you think you've done enough listening to the patient, listen some more. By listening, using our eye contact with the patient, using the body language skills I talked about when speaking, use those same skills and then you'll show the patient that you're focusing on them. You're interested. No distractions. Don't look at your phone. Don't look at the computer. If your beeper goes off, let it go off. You can attend to it once you're done. By showing you're focused, specifically by maintaining eye contact when the patient speaks, it shows a lot about caring. It shows a lot about compassion. It shows a lot about empathy. Just like when speaking, I think when listening, smiling and nodding is more important. You nod again to affirm what the patient is telling you. It shows that you are part of their healthcare team. It shows that you're invested. So smile and nod. And even when you're in a rush, speak slowly. Take a moment to gather your emotions if you're in a rush. And remember to speak slowly, smile and nod. And just as with when you're speaking, body language again, speaks without words. Use that skill set I described in the previous slide to show that you're listening through your body language. Explaining. As I think about explaining, much as we are doing today, I think explaining means to teach and inform. And that's really the main goal with our patient visit. To teach, inform and get them ready for any testing or procedure that they may need. Patients are not coming to the office to get a lecture. Today, through all of our lectures, I believe we're all teaching and informing. We're not lecturing. There's a difference. So teach and inform your patients. When explaining, it's very important to use the words that they understand. I'm being repetitive with this because it's important to individualize patient medical literacy. When necessary, use pictures, graphs and other forms of education material when explaining things. Specifically when you're explaining endoscopic procedures. And maybe the patient's medical literacy isn't the greatest. Use pictures to show them the anatomy of the colon. To show them a picture of the scope and how the scope works. It goes a long way to putting the patient at ease. Patients like up-to-date information. So make sure when you're using guidelines, you let the patients know when you're using them. I like to do it this way when I introduce the guidelines. First I introduce and then I reference. So something like the following. Based on current guidelines from the ASGE on the follow-up of precancerous polyps or adenomas. The current guidelines states. Something as simple as that. Patients really like that. It builds confidence in them for you as their provider. Hey, my nurse practitioner that I saw today was really great. She introduced and told me about the most up-to-date guidelines. She knew what she was talking about. It made me feel really good about my visit and the next step in the testing process. So use the guidelines, introduce them and reference them. In everything we do throughout our interactions with the patient. It's important to be transparent with our discussion. When it comes to testing. When it comes to results. When it comes to referrals and when it comes to plan. We have to be transparent in our discussions and in our documentation. Because patients have access now to our notes. And we want to make sure our discussions and our notes are in line. Teamwork. I think it's important at the initial visit to outline the framework of team approach to care that your practice has. Outline the members of the team. After you see the patient. Okay, we're going to arrange a colonoscopy for you, Mrs. Smith. And the next person you'll see is my nurse. You'll introduce the nurse. And after that, you'll go to the scheduling department. When you come to our practice, we have a number of members of our team and you can name a few. And they'll help you through the entire process. And also remind them that you as the provider are in charge of their care. So if they need to get a hold of you. I think you want to emphasize that patient care extends beyond the office visit. How they can access you, the provider. How they can access your triage nurse. Explain who your triage nurse is. I would tell all my patients at the end of the visit that if you need to get a hold of me, the best place to start is with my triage nurse, Pam. If it's not emergent, I'll be back to you within 24 hours. If it's emergent, we'll get back to you obviously much quicker. And I gave them the option, especially in later years, that they could reach me through email, through an access to report on email. Or they can talk directly to the triage nurse. So give them those options of how you want to best communicate. And most importantly, stress that the patient is not only part of the team and that they must participate, but they are the most important member of the team. And their participation is a must if the management of their care is going to be successful. So what does the patient think about all this? What are they thinking when they come to see you? And I pulled these from another number of studies and surveys. And I think they're very telling and very simple. And I think we've touched on all of these through the talk. So does the provider care about me? Advocacy. Is my provider my healthcare advocate? Again, more advocacy, caring, compassion, empathy. Does my provider listen to me? Hearing and listening, two different things. Do they listen to me? Is my provider friendly and respectful? Remember your body language when being friendly and respectful. Is my provider knowledgeable? Don't forget about those guidelines. Use those guidelines to teach and inform. Does my provider explain things in term I understand? Understanding each person's medical literacy? And will the provider explain any testing that is ordered? These are very, very simple questions that they have, but they tell you really all you need to know about what a patient is thinking when they come to see you. And if you can master these, which you should be able to do very easily, you're all very bright, you become a better provider. All right, let's switch gears now to the science. And I'm really going to focus on the history of present illness, as I said, and the impression and plan. I like to view the history of present illness in a few segments. Intro and purpose. I like to use the acronym OLD CARDS to tell or really build the story I'm about to tell. And then it's a time for a mini review of systems where you bring in those pertinent positives to the specific chief complaint, and then bring in some interval history. If you think of the words of William Osler, who is considered to be the father of internal medicine, he stated that 85% of the time through the history of present illness, he could make the diagnosis. So if you tell a good story in the history of present illness, you're already going to have a great differential diagnosis and likely have the answer. Okay, so intro and purpose, really covering the age, sex, major medical problems. So for example, this is a 72-year-old male with a past medical history significant for atrial fibrillation on chronic anticoagulation. Perhaps there's a little CHF that complicates the atrial fibrillation and CKD stage three. So right off the bat, just by this, we know this person has some chronic medical illness and may be sick. So if they're coming to see us, for example, for something that requires an endoscopic procedure, in my mind and in our minds, we have to start thinking they're on anticoagulation. Can I scope safely? Can I perform an endoscopy safely on anticoagulation? And if they need to be off anticoagulation, what are the risks for the patient? Can I scope now? What's the status of their CKD disease? What type of prep would they need? So just these few little things begin to tell an important story. Old cards. I really like this acronym. It really runs through the most important questions we need to ask to build the story. I'll use as an example abdominal pain. What is the onset of the abdominal pain? What is the location? Right lower quadrant, right upper quadrant. Where is the pain located? What is the duration of pain? Seconds? Minutes? Hours? What's the character of the abdominal pain? Is it sharp? Is it dull? Is it an ache? Aggravating factors. Is it worse with food? Is it worse when I take NSAIDs? Are there any relieving factors? Does food make it better? When I take antacids, it gets better. When I take my PPI, if I had reflux, my reflux gets better. What is the timing and what is the severity? So I like this old cards. I've known about it for decades and I still used it throughout my career to help build the story. It always kept me on point and kept me honest in putting together history of present illness. So unfortunately, I made this man 10 years older in two slides, so I apologize for making him 82 instead of 72, but we'll stick with 72. So a 72-year-old white male, past medical history for atrial fibrillation, chronic anticoagulation, CHF. Now he's sicker. He's got COPD and CKD. He presents for an evaluation of rectal bleeding. Using the old cards, here's the story. He was in his usual state of health until three days ago, onset, when he developed mild lower abdominal pain. So it's mild and it's in the low abdomen. After 30 minutes, some timing, he had an urgent bowel movement with bright red blood mixed with the stool. There was cramping initially that resolved but returned within an hour. He's having three to five bowel movements per day, baseline one to two, and the stools have blood mixed in with bright red blood. He is not taking any antidiarrheal medications. He denies correlation to PO intake. So a lot of information there and not a lot of words. Okay. So we've done our intro. We've used our old cards to tell the story. And so now it's our time to bring in the mini-review systems. And these are additional questions which are pertinent to the chief complaint. And it demonstrates to us how sick the patient is, or perhaps maybe the patient has some slight bright red blood per rectum and they're otherwise completely healthy. It really starts to fill out the story. In general, this doesn't necessarily apply to this particular patient, but in general, questions you want to bring in as part of your review of systems from general fever, chills, or sweats, especially if we're thinking of biliary cholangitis, is there unintentional weight loss? From a cardiopulmonary perspective, it's important to us because we're going to be sedating people or the anesthesiologist is going to be sedating people. So best we know about the cardiopulmonary status. Is there chest pain? Is there dyspnea? Are they dizzy? And GI, these are the pertinent positives to pull in that may or may not have an impact on how we tell our story and how we understand what the patient's current problem is. And finally, to tell the story of the history of present illness is the interval history. This is the latest data that's available, any changes in their clinical course that need to be updated, recent hospitalizations, medication changes, and any new developments that have happened since they've last seen you or if this is a new patient that have happened more recently. And this is where you want to pull in radiographic data, critical labs, hemodynamics. If it's a GI bleeding patient, you may want to talk about the hemodynamics when they present it to the ER. And this is where you want to bring in the prior GI evaluation, last colonoscopy, last upper endoscopy, recent hospitalization notable for, labs are notable for, recent addition of NSAIDs to their medication regimen. So anything new that has come up, put that in and I think you can really build a great history of present illness. I have one brief slide on physical exam. Vital signs are really important part of the physical exam in GI because we deal with so much bleeding, we deal with cholangitis, we deal with unstable pancreatitis patients, we can deal with unstable inflammatory bowel disease patients or in the case of Crohn's infected Crohn's patients. So vital signs very important. I know to meet coding and billing, which you'll hear much more about later from Jill, we need to have all the components of our physical exam to meet certain billing requirements. But when we tell our story for us in GI, we want that focused physical exam, focusing on the general part where we bring in our vitals, focused on the cardiopulmonary exam, focused on the GI exam. Okay, we'll end up with our assessment and plan. And I think the assessment is really your time to shine. The assessment is where we briefly restate the history of present illness. So minimal terminology, tell the story in a nice efficient summary, make sure you have your active issues and complaints that the patient that drove the patient to see you and your time to shine is in the differential diagnosis. This is where we think, think and think some more. After the history of present illness, in my opinion, the differential diagnosis is the next most important part of our evaluation. It helps you formulate and present your evaluation. So you tell a good story to your collaborating physician. So you tell a good story to your referring physicians, and you tell a good story to your patients so they understand what's happening next. If you are doing a continuity visit, it's a nice idea. For instance, their follow up for GERD, is it controlled? Is it not controlled? Is it poorly controlled? Very nice to have that in there. Okay, let's talk about the differential diagnosis, which again, I think is your time to shine. It's your time to show how knowledgeable you are about many different aspects of GI. And I like the acronym vitamin D. So for our patient, the rectal bleeding, is the rectal is the blood in the stool secondary to a vascular cause? Is it secondary to an infectious cause? Is it a toxic or traumatic cause? Is this allergic or autoimmune? Is it metabolic or endocrine related? Is it iatrogenic? Is it a post polypectomy bleed? Is it a neoplasm? Are we worried about a colon cancer? Or is this a drug induced problem? So again, a very nice acronym, vitamin D helps you put together a very nice differential diagnosis. I have an example of a differential diagnosis on the right. If you're a clumper and like to tell a story, this is a very nice, brief paragraph based on your assessment, the most likely diagnosis is XXX. However, given her age and medical history, we need to exclude other conditions such as those, you know, a few other conditions that you may name. It's I always like to put in it's extremely unlikely that a, for example, colon cancer is in the differential diagnosis. So you're letting people know, here's my thoughts of what I think it is, but I really don't think it's this and I think that's important. And then based on the assessment, and after the discussion with the patient, we developed the following plan. I'm more of a lister. I like to use minimal terminology. So I would personally shorten this paragraph, and then list, but I give you both examples. Either way is good, because this is still brief, and it tells a very, very good story. Okay, so this is a 72 year old male with past medical history significant for atrial fibrillation on chronic anticoagulation, CHF, COPD, CKD presents for evaluation of abdominal cramping and rectal bleeding for three days. Nice summary of the story. Recent labs demonstrate acute anemia, symptomatic with fatigue and discipline on exertion. Last colonoscopy was in 2014 and was normal as noted above. Very important piece of information. Hemorrhoidal bleeding and infectious disease are potential differential diagnoses. However, based on his presentation, age, chronic anticoagulation and multiple comorbidities, malignancy and ischemic colitis are also possibilities. IBD is unlikely. It doesn't matter if you tell the story this way. If you're more of a lister, it's okay. Just tell a story like this, that it's easy for people to read and easy for people to understand. The plan is important, obviously. But again, your time to shine. Use your brain. Think, think, think when it comes to the differential diagnosis. Next steps, based on my assessment, after discussion with the patient, we have a list of things we're going to do. Update the CBC. Important piece of information discussed with cardiologists regarding risks and benefits of holding anticoagulation. Colonoscopy under moderate sedation. If you're using monitored anesthesia care, make sure you put that in there. PrEP is noted. Xarelto can be continued if deemed high risk to hold by cardiologists. We discussed that colonoscopy is generally safe. However, risks include adverse events related to sedation, bleeding, infection, perforation, which may require emergency surgery and ostomy. This seems like a lot, but the more you put in there, the more the patient is at ease, the more the patient knows what's going on, and there is a bit of medical legal liability protection. Patient understands, agreeable to proceed, instruction to go to the ED if symptoms develop, and follow up in GI clinic X amount of time. One last point about the plan. If you're seeing someone, for example, in follow-up and they have multiple complaints, it's very helpful. Make sure you separate problem by problem. So I saw a 56-year-old male with a past medical history significant for hypertension, hyperlipidemia, follows up for GERD and chronic constipation. Just list them out. List what you're doing. I think this is a very nice way to list and not necessarily use more words. One final slide on artificial intelligence. Artificial intelligence is coming without question, and it's really going to change the way we practice medicine for you as providers who I'm guessing spend most of your time in the clinic or in the hospital, maybe some time helping out in endoscopy in some way, shape, or form. This is going to have a big impact on your efficiency. It's going to make you more efficient in the clinic. I was at a demonstration of artificial intelligence two years ago at DDW, and it was used to generate the consult, billing, and coding with incredible accuracy. The demonstration was put on by Google by a non-physician who I thought was a physician. He knew so much about medicine, and it took 1.8 seconds to generate the report, including the coding and billing. He was complaining that that was slow, and that was related to their internet connection. He believes it should be less than a second. It's going to increase your efficiency. It's going to give you faster and better access to education materials for your patients so your point of care information you can deliver to the patient and real-time feedback you can give to the patient will be more efficient. But there is a worry here from my perspective. We spent the first part of this talk talking about the art of medicine and how important it is to come off as a caring patient advocate and many other things. Artificial intelligence used properly is great, but as providers, we cannot be perceived as artificial by our patients if we somehow make this an impediment to human interaction. So just keep that in mind. There's more to come in artificial intelligence. In summary, we should all strive to be caring and strong patient advocates. Remember, there's a difference between hearing and listening. We should be good listeners. We should explain through teaching and informing, not lecturing. Teamwork is the foundation of a successful provider-patient relationship. Body language is important and maybe more important than our words. All of our discussions should be transparent, caring, and empathetic. Listen, listen, and listen some more to our patients. As I said, teach and educate, don't lecture, and build that successful team with your patient, with the patient, the focus of that team. Use guidelines, explain to the patients. It helps build confidence in the patient and shows you're an up-to-date, high-quality, high-level provider. Understand each patient's medical literacy. Remember the words of William Ulser, tell an outstanding story in that history of present illness. Come up with a good management plan. The most important part is for you to develop a good differential diagnosis. And this won't be the last time you're going to hear me say this. You're all very smart. You've all worked hard to get where you are. Think, think, and when you're done thinking, think some more. Thank you, and it's now my pleasure to turn this over to Sarah, and she's going to talk to you about optimizing the role of the APP.

gastroenterologist

patient care

communication skills

empathy

active listening

differential diagnosis

artificial intelligence