Date: 2015-2016, 2016-2017 academic years

# of hours: 4

Type of Activity: Small Group Learning

Location: CVH

# of Participants: 6

Today session was exciting.  For the last two years I have been playing around with using fishbone diagrams to help students learn how to take a social history.  I used complex cases to help students appreciate the interconnected nature of patients social determinants of health and their physical well being.  I feel very excited that activities I had experimented with previously are now formally part of the clinical skills curriculum.  So all students across the university will be completing these activities.  As part of the is we developed three cases exploring geriatric health, LGBT health, and refugee health.  It was exciting to watch ideas that I formulated years ago to put into formal curriculum for the benefit of all students.

I was really happy with this session, I do not believe I will be making modifications to it over future years.  I think this is an excellent model for curriculum development.  Experiment locally, then apply successes broadly.

Mrs. James is a 90-year-old widow. She has lived in the same small house for 65 years and has lived alone since her husband died 15 years ago. She has done reasonably well, having no previous surgeries, hospitalization, or major diagnoses. Unfortunately, over the last year she has become increasingly frail and unsteady on her feet. She has had two falls recently, neither of which resulted in any injury. She was not able to get up on her own after the second one and was brought to the emergency room after phoning 911. Thankfully, she did not break her hip and she was sent home. Mrs. James has been prescribed medications for mild heart disease, which she rarely uses. She also takes a sleeping pill (Ativan) as it is difficult to fall asleep at times. Her family consists of two daughters, both living out of town. They are in their late 60s, and one needs to care for her bedridden husband.
At a family meeting, the daughters are pressing Mrs. James to go to a nursing home. They are very concerned she is not coping at home, not eating well, and is going to break a hip with the next fall. They state that Mrs. James sometimes forgets dates and confuses her grandchildren’s names. And even though Mrs. James only drives during the day, her daughters are terrified she will drive over something or someone. They wish you, her physician, to convince her to going into a nursing home. She is sweetly but stubbornly refusing to have anything to do with it.

• What is your differential diagnosis (i.e. What are the possible diagnoses causing the patient’s problem)?
• What additional medical information do you need? How will you ask these questions?
• Create a fishbone diagram to explore and speculate about the underlying causes and the patient’s possible social determinants of health. Provide examples of questions to ask on your social history to attain this information.
• How do patient’s determinants of health:
  • contribute to the etiology of the illness experience
  • aggravate or limit the severity of the illness experience
  • facilitate or interfere with getting well