Challenging Patients Curriculum

The University of Virginia School of Medicine offers a Challenging Patients Curriculum designed to better prepare family medicine residents to meet the needs of elderly patients with multiple chronic illnesses, refugees and immigrants, and patients with chronic pain.The Challenging Patients Program is a three-year progressive curriculum developed through a Residency Training in Primary Care Grant funded by the Department of Health and Human Services, Health Resources and Services Administration (HRSA).  It is built upon the concept of the patient-centered clinical method, and uses a variety of teaching methods to help residents achieve the overall goal of helping physicians reach common ground with patients (i.e., shared, mutually understood goals, and plans of care).  The groups of patients targeted in this program comprise a growing proportion of the U.S. population, require a disproportionate share of healthcare resources, and have specifically been identified as “challenging” by residents in the program.

Curriculum modules and assessment materials for each patient population (elderly with multiple chronic illnesses, refugees and immigrants, patients with chronic pain) have been developed for residents in each of the three post-graduate years of training. These modules also reflect increasing complexity across the three years in order to parallel the developing skills of residents as they move through their training program. Curricula are structured through proposed two-hour workshop formats. Assessments are structured via the use of standardized patients. Curriculum and assessment modules for each patient population (by post graduate year) include the following: 1) a step-by-step guide for instructors to enable them to teach the relevant workshop; 2) all associated handouts, references for reading material, and teaching materials associated with the workshop; and 3) all needed case materials to implement the associated standardized patient case, including standardized patient training materials, case materials for the actual assessment, and associated post-encounter checklists.

The curriculum explores the evaluation and management of the unique medical conditions posed by older patients with multiple co-morbidities, patients with chronic pain, and refugee and immigrant patients, as well as commonly associated psychological co-morbidities, relevant family dynamics and socio-cultural factors. 

The program is grounded in the patient-centered clinical method. The centerpiece of this method is use of patient-centered interviewing methods and an empathic interviewing style to reach common ground with the patient – mutually understood problems and goals of care. The curriculum for each group of challenging patients is taught in a series of workshops that feature a variety of teaching methods, including lectures, role-playing, case discussions, and learning games.

Each year of the curriculum has a standardized patient evaluation that complements the curriculum. The curriculum is provided over three years of residency, with each year’s curriculum building on the residents’ growing competence and sophistication to deal with more complex issues of management in these patients.  For example, in the older patients with multiple co-morbidities curriculum, the first year focuses on aging-disease interactions, using diabetes as a prototypical chronic illness; the second year emphasize practical interdisciplinary geriatric assessment in the context of caring for patients with functional decline; and the third year focuses on finding common ground with patients through a deep understanding of the patient’s and family’s preferences, and the patient’s functional status, medical problems and resources. Each module includes instructors' guides, presentations, handouts and readings, and standardized patient scenarios.