By Rebecca Koppel, Program Manager for Field Building and Resources
“What do you think the patient’s life is like outside of this hospital?”
That’s the question posed by Dr. Anna Doubeni to medical students, residents, fellows, and colleagues. She asks this question because she understands the importance in complex care of understanding the patient’s world, including where they sleep, how they get their food, and what their support system looks like. She finds that this question is difficult for learners to answer while still in the hospital but when she takes them on home visits, they’re able to use all of their senses to see the bigger picture. In that moment, the learner understands how the patient’s life is different from their own and from their assumptions.
Anna says, “One resident was very concerned that a patient was just really fixated on her shoulder pain and wouldn’t do anything else for her health. We went to her house and it wasn’t a house; she was in a room in a boarding house. She had all of her personal belongings from her physical house, which she used to live in, in one room and she couldn’t even roll over in her bed. What worried the patient the most was that every time she tried to roll over to sit up, her shoulder hurt. Afterwards, the resident was like, ‘oh my gosh, I get it now! She can’t do all of those other things we suggested and the biggest thing I can do for her is find a different place for her to live.’ Suddenly the resident saw that she was not just trying to be ‘oppositional’ or get pain medicines. She was trying to manage her life, which is really, really hard.”
Anna brought this experiential training lens to her role as the Education Vice Chair on the working group that developed the complex care core competencies. Alongside her colleagues, she holds several teaching roles at the University of Pennsylvania School of Medicine: she teaches leadership skills to physician and nurse practitioner fellows through the Community Medicine Leadership Fellowship for ACTION, she teaches medical students to develop patient-provider relationships through the Doctoring Program, and she brings residents on patient home visits to help them understand what patients’ lives look like outside of the hospital.
The complex care core competencies that Anna helped create are the base for a new toolkit from the National Center that helps educators and trainers teach the core competencies. Implementing the complex care core competencies: A toolkit to guide education and training, informed by leading complex care education and practice organizations, includes guidance on the design and implementation of effective training and education programs, curated and comprehensive resources designed around the competencies, and case studies and discussion questions. Designed as modules, the toolkit helps educators and trainers identify competencies or domains for which they need support and integrate the resources, case studies, and discussion questions into their education, training, or competency assessment programs. Complex care providers, including Anna, have already begun using the core competencies and the toolkit and find that it helps them teach a different type of care.
Complex care training: Learning from the community
Anna facilitates discussions and case conferences with fellows to share knowledge, experiences, challenges, and successes with community resources. She also finds that these case conferences help with perspective. Last year, she worked with the fellows on the concept of the “difficult patient.” Anna says, “People would say, ‘this is a difficult patient’ and we would talk about reframing that to ‘this is a patient with a very difficult situation, and in reality they’re doing the best they can.’” She says that the principles of complex care can help reframe learners’ attitude in working with patients.
In the Doctoring program that Anna participates in, medical students are taught the value of learning directly from patients. For example, medical students learn about substance use and its impact on health and access to care from a panel of people who have experience using substances. Each group of students then works with a peer specialist who can talk about and answer questions about what it’s like to have struggled with substance use disorder, what it’s like to try to access care, and what it feels like to feel discriminated against because of substance use.
The students also value this time with people with lived experience and Anna has seen that it has lasting impacts on the students. She says that it teaches them to be more understanding, reflective, and caring.
Anna says that learning to be understanding, reflective, and caring is crucial in complex care but that these skills are not always easy to teach. “When learners are in the hospital wards and steeped in the medicine of saving somebody’s life who is decompensating with congestive heart failure at that moment, it’s really difficult to help the learner flip their attention to ask why the patient is back in the hospital and for them to realize that it’s not about ‘non-compliance’ with their medications but it’s about something else.”
However, Anna has found that recent social movements and national conversations around race, poverty, and social determinants of health have shifted learners’ willingness to engage in this content. One of the most powerful tools to engage learners is patient stories; when students can connect those stories to their daily work, their perspective changes.
How Anna uses the complex care core competencies
Anna found that the complex care core competencies helped to justify the work that she was already doing. Whether highlighting a readmission prevention plan during inpatient rounds or supporting a multi-disciplinary care management team meeting, focusing on complex care takes time. Having the core competencies to point to validates the time needed to teach and hone those skills. Anna has also used the core competencies to show that her work is part of a larger complex care movement with nationally-recognized skills, experts, and language.
The core competencies have also helped her structure conversations with her colleagues. Attending physicians will approach her and ask for her advice on supporting their patient with complex needs. Anna will keep the structure of the core competency domains in mind as she answers them to make sure that she covers all of the ways to support a person with complex needs.
Anna also sees that the competencies are useful as a framework in evaluating a complex care team member. Instead of evaluating care managers on the number of phone calls they make, which is not necessarily related to positive patient outcomes, Anna suggests evaluating the care managers using the complex care core competencies. She says, “The leadership of the care management program can now see that some of the skills that we have traditionally called ‘soft skills’ are actually objective, able to be evaluated, and linked to the quality of care delivered.”
How Anna uses the new toolkit to implement the core competencies
Anna has already begun weaving resources from the new toolkit into her training, and is particularly excited about the case studies. She has already used one of the case study scenarios and discussion questions in a learning session with fellows and found that it was helpful in opening up the discussion in new ways.
She introduced the group to scenario #8 about Reginald, the Vietnam veteran who loves telling stories and is also concerned that his PTSD symptoms will lead to a confrontational and potentially violent interaction with the police. Based on this case, the group was able to talk about how systemic racism, interactions between Black men and police officers, and misinterpretations of PTSD symptoms could affect Reginald’s health and well-being.
Anna says, “I think it’s very powerful for students and complex care teams to work and talk through these scenarios before or while they’re working with actual patients. It can be very helpful in team building and understanding the importance of different roles.”
The future of complex care education
Anna looks forward to a future in which complex care is taught through deeper and more meaningful interprofessional education. She is interested in starting consistent interprofessional education at the beginning of an educational journey instead of providing minimal experience on interprofessional teams, which often forces the students to figure out how to work in a team after graduation — And she sees the complex care core competencies as a key tool in this process. Because the core competencies are broadly applicable across disciplines, they can be taught simultaneously to a new medical student, a new pharmacy student, a new social work student, and a new dentistry student. She says, “I hope that with these competencies we can move toward that kind of team learning throughout the educational process for all of the allied health services.”
She also sees that complex care aligns with many other trends in health education, including a focus on health equity, social drivers of health, and person-centered care. She hopes that the growing field of complex care and the core competencies will help more health providers think beyond the walls of the hospital.