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being realistic in managing patients in primary care


BEING REALISTIC -The 6th Item from The Six Interactive Components of Patient Centered Care

BEING REALISTIC Presented by: Dr Nini Shuhaida Mat Harun

Supervised by: Dr Rosnani Zakaria

What does Being Realistic means? Who: Doctor or patient?What: History? Physical examinations? Investigations? Managements?Why?? the benefitWhen: Exam? Practice? How?? will be discussed

Moira Stewart

Intro PatientProblems more complex, multifacetedMany ideasMany concernsMore expectations

Doctor Time constrainLimited resourcesPhysical & emotional energyTeamworkBeing realistic in pt careManages resources, especially time and energy, to provide optimal care for the patient in the context of whole practice in the community in which the physician works.

Canadian Medical Association Journal, April 15, 2003; 168, 8; ProQuest Central, pg. 957Time & timing Research has shown that visits in which the pt are active participants in telling about their illness and in asking questions are almost identical in length to other visits. Dont be afraid because your time wont waste by giving your pt time to talk.

Length of consultation can be as brief as 5 minutes (in UK) , 12 minutes in Australia.Recent studies the length of time family physicians spend with patient has increase by 2 minutes approximately 17 minutes.

(Blumenthal et al.,; 1999, Mechanic et al., 2001 ; Stafford et al.,1999)

Pt as active participant: The best use of resources over long term, Potentially saving the pt from return to other visit for more accurate recognition of problems,Leading to fewer unnecessary tests and referrals.

All because his problems have been more appropriately prioritized. Not to deal with all problems in every pt in each visits BUT must able to recognize when a pt need more time. How to prioritize pts problem? Guided by pts expressed concerns, andThe potential seriousness of the problems. (eg: child abuse, suicidal ideation, woman abuse, life-threatening medical situation)

Must know how to create quickly an atmosphere in which patients feel heard and understood and feel their problems are important.

Essential skills for physicians flexibility and readiness to respond in a manner that express both concern and willingness to work with patient in a future.IMPORTANT!!!The doctor needs to acknowledge the pts concerns.Depend on time and availabilityAt the moment, orFurther f/upIf not:Unnecessary use of resources at subsequent visitsIncrease cost of Mx Pt demand further visits, additional Ix, unwarranted procedures, Pt and doctor dissatisfaction

Accessing Resources and TeambuildingNot expected to be knowledgeable about every available resource in community for each specific group BUTMust be prepared to learn about the context in which the pt live and how to access the appropriate resources. knowing the key personnel who can locate, motivate and promote changes. In other words; works in a team and adopt a position of shared responsibility and power. No one profession can meet all the pts needs, hence the need to work together in teams. There are strengths, but also pitfalls in teamwork. There are also misconceptions about what teamwork is. McWhinney (1989)Successful team building3 approaches:Coordination (multidisciplinary)Cooperation (interdisciplinary)Collaboration (transdisciplinary)Multidisciplinary Promotes the achievement of multiple goals and tasks in health care delivery by multiple participants. Disadvantages: Compartmentalize healthcare deliveryMay result in duplication of services or gaps in serviceFrom patients perspective fragmented care and confusion about accessing and using appropriate resources. Interdisciplinary Each discipline works independently but in concert with other members to address particular pt needs. Disadvantages: Tends to be case specific.Does not ensure integrated team functioning. Much time and effort may be consumed in negotiating professional roles and extent of involvements. Fragmented care and confusion about service delivery pt experience. Transdisciplinary More flexible and crosses disciplinary boundaries. Requires more equitable distribution of responsibility and power. Lead to increase comprehensive pt care. Active involvement of the pt in all phases of planning and implementing their care equal participants. Wise stewardshipExhibits wise stewardship of limited community resources: balances need of individual patients with the needs of the community

Constantly making a conscious choice in determining value trade-offs between pts needs / wants and resources available.

A penny of good communication time may avert a pound of unnecessary or even harmful spending used to reassure an anxious patient or substitute for a sketchy history

Goold and Lipkin (1999)

Case scenarioCASE SCENARIOCase scenario 1 33y/o Malay ladyG6P5,@34/52 POG : placenta praevia type IVFHx: children aged: 12,10,8,5,3 husband: labourer patient: housewife

Doctors view: need for admission afraid risk of bleeding / complications

Patients view: refused for admission : reason- nobody to take care the children - husband working- unable to take long leave : promise will take care herself

What are you supposed to do ?

Follow patient request ?

How to negotiate with patient ?

To be realistic..PatientTime: anytime available?

Human resources: anybody available if need to send her urgently to the hospital?

Physical resources: any transport available ?

DoctorTime: anytime available?

Human resources: can ask JM to do home visit and if encounter any problem to let you know for further action if, patient came to clinic, is it anybody available to entertain her? get advice from O+G team- to anticipate problem if anything happen

Physical resources: can provide clinic phone no, if need ambulance or further care

If bleeding occur, and patient must be hospitalised.Who will take care her children?? Husband? Parents? In laws? Neighbour?

All children need to stay at their own house or go to people that can take care them?

After discuss ---- decision...

Case scenario 270y/o manHistory of DM, Hypertensionc/o: swelling over the back for 3 days a/w low grade fever O/E: carbuncle over the back, need saucerization. T: 37.5C Dxt: 16mmol/L clinically not septic lookingFHx: stay with wife (70y/o)-stroke, bedridden, taking care wife on his own A son, stay far-have own family

PatientRefuse for admission

Nobody take care wife

Need to wait for child to come home

Doctors viewNeed for admission

Goal treatment: saucerization and diabetic control

If delay can progress into sepsis

What are you supposed to do?

scold patient and force him for admission?

ask other colleague to recounsel patient?

ask patient to sign AOR form?

follow patient request? Negotiate?Being realistic.PatientTime: only available when his child came back home / other relatives come to take care his wife

Human resources: children/relatives? neighbour

Physical resources: any transport available, if need to come to hospital urgently

DoctorTime: can come anytime, if need hospitalization- arrange to the nearest hospital

Human resources: MA/nurses need to remind re :follow-up, if stay near patients house can monitor progress if patient came with sepsis, early intervention needed, so need to equip staff to do resuscitation before further referral

Physical resources: ambulance available? emergency trolleyWhat we can do if patient still refuse admission after counseling.We can give antibiotic for a mean time, but still advise the patient to come to clinic/ nearest hospital if condition worsen.

Advise patient to control sugar can increase dosage / assess compliance

Advise to inform child re: his condition and what Drs advise and also to inform friends and ask for help if anything happen.

Give patient open appointment to come to see you if he change mind.

Conclusions Let the pt express his problems and ask questions pt as active participant.Prioritize the pt illness/ problems.Address the pts problems in effective and efficient manner.Know the key personnel who can locate, motivate and promote changes team work.balances need of individual patients with the needs of the community.Referrences Patient-centered Medicine: Transforming the Clinical Method; Moira Stewart, Judith Belle Brown et. al. British Journal of General Practice, October 2005

THANK YOUIn the hands of GPs, I have watched the patients confusion, fear and doubt transform to clarity, relief and assurance. There is still confusion all around but there is a time of insight, healing and new positive energy within the patient to engage the situation. Without the GP in this role, there would continue to be more confusion, fear and doubt. With the GP in this role, sick people recover, sick people find relief from suffering, some sick people fear less, and some sick people are filled with hope. This is general practices precious gift to humanity.

-Moira Stewart-