MMI Core Principles

The basics of what you need to know for an MMI

Reasonable patient standard

Disclose what a typical patient would reasonably want to know about their care, not just what the doctor thinks matters.

Deception by omission

Leaving out information a patient would want to know. It can feel like lying when they find out later.

Accountability for AI-drafted messages

The physician who signs or sends the message is fully responsible for its content, no matter who or what drafted it.

Why health systems use AI drafting

Patient portal messages have increased a lot, adding after-hours work and contributing to physician burnout.

AI and health equity

AI may work less well for some groups, like patients with limited English or those underrepresented in its training data. Watch for uneven effects.

Engaging with evidence against your view

Acknowledge the data, explain what it shows, then weigh it against other harms before deciding whether to change your position.

Speaking for the team

When a patient is upset with the system, take responsibility on the team's behalf ("We should have been clearer") instead of defending the policy.

Expand the resource first

Before choosing between patients, look for ways to create more capacity, like an extra slot, another clinic, or a different visit type.

Teledermatology

Remote skin care, often by sending photos for a dermatologist to review. Useful for triaging which cases are most urgent.

Transparent allocation policy

A written rule for sharing scarce resources that is applied the same way to everyone and explained to patients.

Age as a criterion

Don't use age alone to decide who gets care. Consider it only when it truly affects medical need or benefit.

Structural barriers

Obstacles outside a person's control, like hourly jobs without paid leave, that make it hard to get care. Not the same as not caring.

Utilitarian approach

Give the resource where it does the most total good, such as to the patient most likely to benefit.

Egalitarian approach

Give everyone an equal chance, such as through a lottery or waitlist order.

Prioritarian approach

Give priority to the worst off, such as the sickest patient or the one with the fewest other options.

Recommend vs. decide

When asked to recommend, give a clear recommendation with your reasoning, and note that the final decision belongs to the person in charge.

ABCDE skin cancer warning signs

Asymmetry, irregular Border, uneven Color, Diameter larger than about 6 mm, and Evolving (changing over time).

Backup plan for a scarce slot

Tell the chosen patient to give notice if they can't come, and keep the next patient ready to take the slot.

UCSD AI policy

AI supports but never replaces clinical judgment. Every tool is reviewed by a multidisciplinary committee (including ethics and health equity), monitored over time, and measured for impact. AI notetaking is used only with patient permission. AI-drafted portal messages include a disclosure that the named physician reviewed and edited them, because transparency protects trust.

Ethics committee

A hospital team of doctors, nurses, social workers, ethicists, chaplains, lawyers, and community members. Anyone involved in care can request a consult. It gives recommendations, not binding decisions.

When to use an ethics committee

When a serious conflict continues after direct conversation and involving the attending, such as disagreements about life support, surrogate decisions, or treatment that may not help. Mention it as a later step, not your first move.

Ask the patient privately

Ask the patient how much she wants to know without family in the room, so her answer is truly her own and not influenced by anyone.

Don't confirm results to family first

Before the patient agrees, don't share or confirm her diagnosis. Say: "I can't discuss your mother's results before we speak with her, but I hear how much you care about her."

Patient chooses not to know

Document who she wants to receive her information, tell her she can change her mind at any time, and still involve her in major treatment decisions.

Be curious about the family's fears

Ask what they're worried about, like their mother losing hope or suffering. Treat the family as allies, not obstacles.

Fentanyl in street opioids

Pills and powders bought illegally often contain fentanyl, a very strong opioid. Even a small amount can cause a deadly overdose.

Tolerance during a taper

As the dose is lowered, the body gets used to less. If the patient then takes their old amount or street drugs, that amount can now cause an overdose.

Naloxone

A medication (such as Narcan nasal spray) that reverses an opioid overdose. Offer it to patients at risk and their families.

Physical dependence vs. addiction

Dependence: the body adapts and has withdrawal if the drug stops, which is expected with long-term use. Addiction (opioid use disorder): cravings, loss of control, and continued use despite harm.

Treating opioid addiction

If addiction is a concern, screen without judgment. Effective treatment exists, such as buprenorphine.

Don't stop opioids abruptly

Stopping suddenly can cause withdrawal and uncontrolled pain, and can push patients toward street drugs. Lower the dose slowly, with the patient involved.

Patient walks out of the clinic

Let a capable adult leave. Then call them, leave the door open, don't stop their medication abruptly, offer naloxone and resources, and document everything.

When to call security

Only when there is immediate danger to the patient or others. Not to bring back a capable adult who chose to leave.

Validate without over-apologizing

Say "It sounds like you've felt judged before, and that isn't okay," instead of "We apologize for making you feel that way."

Student role with an upset patient

Listen, gather their history and concerns, and share them with the attending. Let the attending explain treatment changes.

Health effects of losing coverage

Losing health coverage can make chronic illness worse, which makes it harder to work. It can create a cycle.

Coverage churn

When people lose and regain coverage because of paperwork problems, interrupting their care even though they qualify.

Automatic verification

A middle path for work requirements: the state uses data it already has, like wage records, to confirm work or exemptions so people don't lose coverage over paperwork.

Evidence on Medicaid work requirements

When Arkansas tried them in 2018, thousands lost coverage, many were already working or should have been exempt, and employment did not clearly increase.

Patient loses insulin coverage

Treat it as urgent, because going without insulin can become life-threatening quickly. Make sure they have insulin today, involve a social worker, check manufacturer assistance programs and the clinic pharmacy, and help them reapply.

Blood thinner overdose

The patient needs close monitoring for bleeding, so the attending must know right away, not eventually.

Honest error disclosure wording

Avoid minimizing, like "not to worry." Say: "We're monitoring you closely for bleeding, and we'll keep you updated."

Just culture

Hospitals encourage error reporting to fix systems, not to blame individuals. Discipline is only for reckless behavior or repeated hiding of errors.

Near miss

An error that was caught before it caused harm. Report it anyway, because it reveals weak spots in the system.

System fixes after an error

Examples: order alerts for unusual doses, dose limits, pharmacist or nurse double checks, and a team debrief.

Nurse catches an error

Shows the safety system working. Multiple checks exist so one person's mistake doesn't reach the patient.

Threat of retaliation

Report the error anyway. Raise the retaliation concern with the attending or clerkship director. Schools have policies against retaliation.

Passive suicidal thoughts

Statements like "I wish I didn't wake up" are a safety warning. Always take them seriously and ask more.

Asking directly about suicide

Gently ask: "Are you having thoughts of ending your life? Do you have a plan? Do you have access to anything you could use to hurt yourself?"

Does asking about suicide increase risk?

No. Asking directly does not put the idea in someone's head, and it shows you take them seriously.

Access to means

Ask about medications, firearms, or other ways a person could hurt themselves. Limiting access can save lives.

Honesty about confidentiality

Don't promise to keep a safety concern secret. Say: "Because I care about your safety, I need to share this with the doctor I'm working with. It stays within your care team."

Documenting sensitive information

Clinicians must document safety concerns, but medical records are private. Parents can't see an adult patient's records without permission.

Adult patients and parents

Once a patient is 18 or older, parents aren't told about their health without the patient's permission, unless it's needed to prevent serious and immediate harm.

988 Suicide and Crisis Lifeline

Call or text 988 for free, 24/7 support during a mental health crisis.

Safety plan

A plan made with the patient that lists warning signs, coping strategies, people to contact, and crisis resources.

Asking about support

"Is there anyone you trust who could support you right now?"

Driving safety warning signs

Getting lost on familiar routes, new dents or scrapes on the car, near misses, and concerns from family.

Public safety as a stakeholder

Unsafe driving puts pedestrians and other drivers at risk, not just the patient. The tension becomes his independence vs. his safety and the public's safety.

Formal driving evaluation

A test by a specialist, such as an occupational therapist, to objectively check whether someone can drive safely.

Driving middle paths

If an evaluation allows it: daytime-only driving, familiar routes, and no highways.

Protecting independence without driving

Ask what driving lets the patient do, like shopping or seeing friends, then solve for those needs with family rides, senior shuttles, ride services, or delivery.

Handling a family member's private concerns

Bring up what the family shared gently, so the patient doesn't feel ambushed or betrayed.

Dementia and driving reporting

In California, doctors must report certain conditions, including dementia that may affect driving, which can lead to a DMV review. Say: "The attending would know the reporting rules."

Letting go of a project

If a tool or project isn't safe enough, accept stopping it. Patient safety comes before how much work went into it.

AI safeguards

Check accuracy on new patients over time, make sure the tool works equally well for different patient groups, and tell families it's only a support tool.

Core of an opening answer

Name the tension, show empathy, notice any safety or privacy concern, state your position, and mention one middle path. Save the rest for follow-ups.

When unsure about a medical fact

Don't guess confidently. Say: "I'd want to learn more about that," or "I'd ask the attending."

Facts vs. judgment in MMIs

You don't need medical knowledge. You do need to notice danger, respect privacy, be honest, and know your role.