Even setting aside the once-in-a-lifetime impact of the pandemic, the physician’s role in 2020 is substantially different than it was a decade ago. Today’s patients are often sicker, and illness is compounded by numerous nonbiomedical factors, such as inadequate social support to comply with treatment plans and avoid unnecessary hospitalizations.
The COVID-19 pandemic is complicating things further by stalling many clinical research and quality improvement efforts. But a project funded by a grant from the AMA Accelerating Change in Medical Education initiative continues training students at four U.S. medical schools to incorporate a new history and physical (H&P) model—the H&P 360—to collect biopsychosocial data, better manage chronic disease and address social determinants of health.
The four medical schools receiving the H&P 360 implementation grants are the University of Michigan, Eastern Virginia Medical School, Florida International University and University of Chicago.
Focus on chronic disease
While the H&P is the primary process through which a physician obtains key subjective and objective patient information, the traditional H&P was developed decades ago when the physician’s role was more limited.
“Medical practice is necessarily undergoing a paradigm shift, and the new paradigm has to do with accounting for social determinants and behavioral health,” said Brent Williams, MD, MPH, director of the Global Health and Disparities Path of Excellence at University of Michigan Medical School.
“The H&P 360 is meant to help physicians stop making the mistakes that are in built into the old medical paradigm, which is based exclusively on biomedical disease diagnosis and treatment,” Dr. Williams added. “It pushes them to take a realistic view of why so many patients bounce back into the hospital—for example, because they didn't have access to their medications or they didn't take them appropriately.”
Based on a format developed at University of Michigan Medical School, the H&P 360 was expanded and refined by the AMA’s Chronic Disease Prevention and Management interest group in 2017 and piloted at four medical schools in 2018.
The idea behind the H&P 360 is that by including at least a few questions in each of six domains besides the traditional biomedical information in the routine history, physicians’ care of patients will improve.
Those additional domains are:
- Patients’ perceptions of health, goals and values.
- Mental health conditions.
- Behavioral health.
- Social support.
- Environmental or physical resources.
- Function.
For example, in the relationships domain, students are being trained to assess the level of support available to their patients. They might ask questions such as:
- “Who do you turn to when life gets stressful?”
- “Are you afraid you might be hurt in your apartment building or house?”
- “Who do you rely on when you are unable to do something yourself?”
- “What community resources or programs do you use to improve or maintain your health?”
Clinical trial results
The effectiveness of the H&P 360 is supported by a 2019 randomized-controlled trial with standardized patients. Nearly 160 third- and fourth-year medical students at four medical schools—University of Michigan, University of North Dakota, University of Connecticut and University of California, Davis—were randomly assigned to either the traditional H&P or the H&P 360 and further randomized to either see a patient with hypertension or a patient with type 2 diabetes.
For each encounter, a standardized patient doubled as a trained observer and completed a grading rubric that measured:
- How well the student captured key clinical data from the patient.
- Student success in integrating interdisciplinary team, patient, family or community resources into the assessment and management plan.
- Level of inclusion of social-behavioral information into the assessment and management plan.
- Student empathy and other verbal or nonverbal communication skills.
Analysis of the data demonstrated average total scores on the performance rubric were substantially higher among the intervention group in both cases, at all four schools and across all four standardized patients.
How virtual visits boost new H&P
Dr. Williams noted that the grant group’s students have returned to clinical settings and are now implementing H&P 360 during both in-person and virtual visits.
“While the pandemic has disrupted or delayed some of the work, it has also made it easier to apply the H&P 360,” he said. “With video visits, medical students are drawn more directly into patients’ living environments and social support systems.”
No matter the type of visit, however, what makes the H&P 360 such a practical tool is that it’s not a checklist that has to be included in every visit, Dr. Williams added. “By gathering just two or three pieces of information each time, the physician will gradually get a more complete picture of a patient’s health and the paths to improvement.”
The long-term goal for H&P 360 is to make it the standard tool in medical practice for improvement of all aspects of chronic disease prevention, diagnosis, treatment and management. The H&P 360 template and supporting materials are available for use at all medical schools.
