Module 3: Incorporating a Prevention History into the Medical Interview
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Transcript of Module 3: Incorporating a Prevention History into the Medical Interview
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Module 3:Incorporating a Prevention History into the Medical Interview
Developed through the APTR Initiative to Enhance Prevention and Population Health Education in collaboration with the Brody School of Medicine at East Carolina University with funding from the Centers for Disease Control and Prevention
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Acknowledgments
APTR wishes to acknowledge the following individual that developed this module:
Suzanne Lazorick, MD, MPHDepartments of Pediatrics and Public HealthBrody School of Medicine at East Carolina University
This education module is made possible through the Centers for Disease Control and Prevention (CDC) and the Association for Prevention Teaching and Research (APTR) Cooperative Agreement, No. 5U50CD300860. The module represents the opinions of the author(s) and does not necessarily represent the views of the Centers for Disease Control and Prevention or the Association for Prevention Teaching and Research.
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Presentation Objectives
1. Discuss the importance of prevention in terms of patient goals, health outcomes and economic impact
2. Describe strategies for incorporating prevention when obtaining a patient’s medical history
3. Describe and categorize the essential elements of a preventive history
4. Identify age-appropriate screening activities using the Age-Specific Preventive History Cards
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Patient goals: What do patients come to a medical provider for?
Help with a specific problem Treatment of one or more problems To feel better To be healthier To live longer
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“The physician’s function is fast becoming social and preventative, rather than being individual and curative. Upon him society relies to ascertain, and through measures essentially educational, to enforce conditions to prevent disease…”
Abraham FlexnerThe Flexner Report on Medical Education in the United States and Canada, 1910
Abraham Flexner, 1910
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Age-adjusted percentages of persons aged ≥20 years with diabetes, by county — United States, 2007
www.cdc.gov/mmwr November 20, 2009 / Vol. 58 / No. 45
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Outcomes: Leading Causes of Death
Heart Disease Cancer Stroke Respiratory Diseases Injuries
Diabetes Alzheimer’s Disease Pneumonia/Flu Kidney Disease Septicemia
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Leading Preventable * Causes of Death
Heart Disease* Cancer* Stroke* Respiratory Diseases* Injuries*
Diabetes* Alzheimer’s Disease?
Pneumonia/Flu* Kidney Disease* Septicemia*
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1.5%
1.9%
2.7%
2.9%
4.0%
5.2%
7.0%
23.0%
30.4%
0% 10% 20% 30% 40%
Nephritis and nephrosis
Alzheimer's disease
Influenza and pneumonia
Diabetes mellitus
Unintentional injuries
Chronic obstructive pulmonary disease
Stroke
All cancers
Diseases of the heart
Percent of all deaths
Causes of Death, United States 2000
Source: Mokdad A, Marks JS, Stroup DE, Gerberding JL. Actual causes of death in the United States. JAMA 2004; 291(10):1238-1245. Correction published JAMA 2005; 293(3): 293-294.
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Source: Mokdad A, Marks JS, Stroup DE, Gerberding JL. Actual causes of death in the United States. JAMA 2004; 291(10):1238-1245. Correction published JAMA 2005; 293(3): 293-294.
18.1%
15.2%
3.5%
3.1%
2.3%
1.8%
1.2%
0.8%
0.7%
0% 5% 10% 15% 20%
Illicit Drug Use
Sexual Behavior
Firearms
Motor Vehicles
Pollution/Toxic
Infectious Agents
Alcohol Consumption
Poor Diet and Physical Activity
Smoking
Percent of all deaths
Underlying Causes of Death, United States 2000
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Rethinking Current Approaches
80% ofCosts
Stem from preventable chronic
conditions
75% ofcosts
20% ofclaimants
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Importance of PreventionEconomic Impact
Every $1 spent on immunization saves $16.50 in medical costs and indirect costs, such as disability.
Every $10 bike helmet generates $570 in benefits to society.
Zhou, et al., 2005, Child Safety Network, 2005.
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“I will prevent disease whenever I can, for prevention is preferable to cure.”
Hippocratic Oath (Modern Version)
Abraham Flexner, 1910
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Strategies for Incorporating Prevention
Abraham Flexner, 1910
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Collect preventive history information as part of your routine care Outpatient Inpatient Know what patients need
▪ Reinforce prevention messages ▪ Then either arrange for it or refer to primary care!
Incorporating Prevention into the Patient History
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Typical Complete Medical Interview
Chief complaint and History of Present illness Past Medical History Family History Social History Prevention (items not covered in other sections) Vital Signs and Physical Exam Assessment and Plan
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Incorporate a Prevention History Past Medical History
Existing medical conditions (in numbered list format, including date of onset)
Major Hospitalizations (include dates) Major surgical history (include dates)
Specific female screening for: mammogram, Pap smear, bone density (fractures, height loss)
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Family health record (e.g. siblings, parents, and grandparents) age and health status if deceased, cause of death
History of screening for diseases specific to known family history
Incorporate a Prevention History Family History
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Home/ Household Work/educational history Support systems Cultural background Travel history Risk of TB or hepatitis exposure Substance Use/Abuse Diet/Physical activity habits Safety Measures Sexual history
Incorporate a Prevention History Social History
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Incorporate a Prevention History Additional prevention needs
Age-Appropriate Screenings blood pressure diabetes lipids colon cancer depression weight problems sexually transmitted
infections (STIs)
Immunizations Influenza pneumococcal pertussis tetanus varicella hepatitis A and B MMR meningococcal HPV receipt of BCG vaccine for TB
in another country
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Vital Signs temperature heart rate blood pressure respiratory rate
Anthropometrics height weight body mass index (BMI)
Incorporate a Prevention History Physical Exam
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Cancer and chronic disease screening Lifestyle/habits STIs/contraception Immunizations
Incorporate a Prevention History Categories of Prevention Needs
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Plan: 1. Continue blood pressure medicine, educated re: low
salt and low fat diet, exercise, and decrease alcohol2. Encouraged smoking cessation3. Apply for medication assistance program4. Prevention needs: Flu shot today; encouraged
continued daily walking and decreasing fried foods; overdue for colon cancer screening- schedule colonoscopy.
5. Follow-up in 3 months
Incorporate a Prevention History Example of a Patient Treatment Plan
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Age-Specific Preventive History Cards
Abraham Flexner, 1910
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Practice Cases
56 year old man comes to the office for routine hypertension follow up
21 year old man presents with a knee injury
28 year old woman in for consultation about Lasik surgery presents to Ophthalmology office
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Practical Tips
Know your setting Provide recommendations accordingly Look for “teachable moments”
Cover what you can; prioritize You will not always have to do it all Use office systems and staff to put routines in place
▪ Electronic Health Records (EHR) Make notes if you cannot cover it all
Document needs for future visits Collaborate with colleagues across disciplines to
incorporate prevention in a variety of settings
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Additional Resources
Video demonstration of a patient history incorporating the prevention history components (available as a separate file for viewing)
Part B of this module – a slide set that covers evidence-based prevention and the US Preventive Services Task Force
A pdf of the Age-Specific Preventive History Cards is available on the project website, or cards can be obtained through the Department of Public Health at the Brody School of Medicine
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Summary
Prevention is a critical part of comprehensive, efficient and evidence-based care of all patients
Assessing a patient’s medical history should include age-appropriate prevention
Patients prevention needs can be assessed in all medical settings and encounters
Tools and resources are available to assist medical providers
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Collaborating Institutions
Center for Public Health Continuing EducationUniversity at Albany School of Public Health
Department of Community & Family MedicineDuke University School of Medicine
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Advisory Committee
Mike Barry, CAELorrie Basnight, MDNancy Bennett, MD, MSRuth Gaare Bernheim, JD, MPHAmber Berrian, MPHJames Cawley, MPH, PA-CJack Dillenberg, DDS, MPHKristine Gebbie, RN, DrPHAsim Jani, MD, MPH, FACP
Denise Koo, MD, MPHSuzanne Lazorick, MD, MPHRika Maeshiro, MD, MPHDan Mareck, MDSteve McCurdy, MD, MPHSusan M. Meyer, PhDSallie Rixey, MD, MEdNawraz Shawir, MBBS
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APTR
Sharon Hull, MD, MPHPresident
Allison L. LewisExecutive Director
O. Kent Nordvig, MEdProject Representative