Lower Limb Ischemia in Atrial Fibrillation: Unusual Presentation

Introduction: Thrombosis and embolism are the common causes of acute arterial occlusion. Thrombosis mostly arises from underlying cardiac disease such as a trial fibrillation while arterial occlusion by embolism. Thus, an ischemic limb can result from acute arterial occlusion. Early proper diagnosis and prompt treatment within critical time by emergency physician at the initial clinical interviewing is important in saving the affected leg and the life, thus, avoiding limb amputation and death. This paper reports a case in which the cause of acute ischemia of limb was proved with some diagnostic tests to be a trial fibrillation.

SETTING A COMMON GROUND FOR COLLABORATIVE CARE AND CLINICAL INTERVIEWING

Background: A relationship and communication matrix and collaborative assessment and care, as part of a set of elicited principles and strategies, are hallmarks of person-centered medicine and health care. Their formulation and cultivation have been predicated on both humanistic and scientific grounds. Objectives: This paper is aimed at articulating the bases, key concepts, and strategies for establishing common ground among clinicians, patient, and family for organizing all person-centered clinical care, starting with clinical interviews. Method: For addressing these objectives, a selective review of the clinical literature was conducted. This was complemented by contrasting the findings with the results of similar papers and reflecting on their implications. Results: One of the broadest and most compelling factors for organizing person centered clinical care effectively in general, and particularly concerning interviewing, assessment, and diagnosis as well as treatment planning and implementation, seems to be setting up common ground among clinicians, patient, and family. Crucial dynamic matrices of common ground seem to be (1) assembling and engaging the key players for effective care, (2) establishing empathetic communication among these players, (3) organizing participative diagnostic processes toward joint understanding of the presenting person’s personhood and health (both problems and positive aspects), and (4) planning and implementing clinical care through shared decision making and joint commitments. Critical guiding considerations for common ground appear to include holistic informational integration, taking into consideration the person’s chronological and space context, and attending to his or her health experience, preferences, and values. Among the most promising strategies for operationalizing common ground is the formulation of a narrative integrative synthesis of clinical and personal information as joint distillation of the assessment process and as foundation for planning care. These considerations also serve as framework for the delineation and organization of effective clinical interviewing. Discussion: These findings are supported, first, by historical and anthropological research, which elucidates health care as part of social cooperation for the preservation and promotion of life. Common ground appears substantiated by the principles of person centered medicine, and represents one of its most clear projections. Also supportive of common ground is recent research on the positive perceptions of clinicians on procedures that are culturally informed and consider personal experience and values. Conclusions: It appears that the establishment of a common ground among clinicians, patient, and family is a critical step for the effective person-centered organization of clinical care in general and for interviewing, diagnosis, and treatment planning in particular.

Dreyfus scale-based feedback increased medical students’ satisfaction with the complex cluster part of a interviewing and physical examination course and improved skills readiness in Taiwan

Purpose: In contrast to the core part of the clinical interviewing and physical examination (PE) skills course, corresponding to the basic, head-to-toe, and thoracic systems, learners need structured feedback in the cluster part of the course, which includes the abdominal, neuromuscular, and musculoskeletal systems. This study evaluated the effects of using Dreyfus scale-based feedback, which has elements of continuous professional development, instead of Likert scale-based feedback in the cluster part of training in Taiwan.Methods: Instructors and final-year medical students in the 2015–2016 classes of National Yang-Ming University, Taiwan comprised the regular cohort, whereas those in the 2017–2018 classes formed the intervention cohort. In the intervention cohort, Dreyfus scale-based feedback, rather than Likert scale-based feedback, was used in the cluster part of the course.Results: In the cluster part of the course in the regular cohort, pre-trained standardized patients rated the class climate as poor, and students expressed low satisfaction with the instructors and course and low self-assessed readiness. In comparison with the regular cohort, improved end-of-course group objective structured clinical examination scores after the cluster part were noted in the intervention cohort. In other words, the implementation of Dreyfus scale-based feedback in the intervention cohort for the cluster part improved the deficit in this section of the course.Conclusion: The implementation of Dreyfus scale-based feedback helped instructors to create a good class climate in the cluster part of the clinical interviewing and PE skills course. Simultaneously, this new intervention achieved the goal of promoting medical students’ readiness for interviewing, PE, and self-directed learning.

Assessing Family Accommodation

Addressing family accommodation begins with assessing the extent and form of accommodations being provided. Assessing family accommodation should be part of the broader assessment plan when evaluating childhood anxiety and obsessive-compulsive disorder. This chapter provides guidelines and tools for the initial assessment of family accommodation. Methods of assessing family accommodation include clinical interviewing and structured rating scales. The chapter provides many examples and suggestions for ways to broach the topic of family accommodation with parents in an empathic and nonjudgmental manner. The chapter also provides detailed information on the currently available rating scales for measuring family accommodation and the relative advantages of each tool.