PATIENT CENTRED CLINICAL METHOD

M.O. Ogunsanya

Outline
Overview Doctor(Dx Oriented) Clinical Methods(DCCM) Patient Centred Clinical Methods Patient Centred Care Elements of PCCM Components of PCCM Patient Centred Consultation Case Study

Overview
Health professionals do not deal with disease; they deal with people who are concerned about their health. Patient Centred Clinical Method (PCCM) is a clinical method designed to elicit an understanding of the patient and his disease. PCCM looks at 2 agendas namely, the Physicians and the Patients.

PATIENT PRESENTS CUES OF UNWELLNESS DOCTOR SEARCHES TWO PARALLEL AGENDAS

DOCTORS AGENDA - Hx - PE - Lab Investigation

PATIENTS AGENDA

UNDERSTANDING ILLNESS EXPERIENCE

DIFFERENTIAL DIAGNOSIS

INTEGRATION
The Patience-centered Clinical Method

Doctor(Disease Oriented) Centred Clinical Method (DCCM)

Method used by most practitioners and taught in medical school. In doctor centred consultations, their medical skills and knowledge predominate. They maintain control by using closed questions and giving the patient directions. The patients perceptions and preferences are not explored.

Patient Centred Clinical Methods (PCCM)

Focus began in the 1970s when The two terms DCCM and PCCM were coined PCCM practiced partially in private settings though practitioners unaware of this Platform for ensuring Patient Centred Care What then is Patient Centred Care?

Patient Centered Care

Being patient centered means health care providers take into account the patients desire for information and for sharing decision making. Patient centered care requires a thorough explanation of disease to patients and exploration of their feelings, beliefs and expectations.

Patient Centered Care

It is the interaction between the clinician and the patient, and the clinicians ability to use the patients knowledge and experiences to guide the consultation. Patient centred interviews recognize patients needs and preferences by encouraging them to voice ideas and collaborate in the consultation.

Patient Centred Care

Patient centred care is not: - technology centred - doctor centred - hospital centred - disease centred Rather these components revolve around the patient.

Why Patient Centred Care?

Enhances patient satisfaction Improves patient outcomes Has a positive impact on health care utilization costs Is associated with positive benefits for health professionals such as greater job satisfaction Is associated with fewer malpractice claims

Fundamental Elements of PCC

Elements fundamental to patient centred care are: - Respect for the individuals values, expressed needs and preferences. - Choice patients have the right and responsibility to participate in health care decisions including treatment and management.

Fundamental Elements of PCC(cont)

- Access to services required by the persons medical condition, including preventive care. - Support acknowledging and addressing the persons emotional and social needs. This means involving the persons family and friends (as the patient desires) and considering educational, cultural and personal factors affecting the persons ability to manage their condition.

Fundamental Elements of PCC(cont)

- Education and information that is accurate, relevant and answers the persons concerns.

PCCM - Clinical Consultation in PCC

Clinicians skills to customize care to the specific needs and circumstances of each individual, that is, to modify care to respond to the person, not the person to the care. Clinicians to think about ways of integrating patients perceptions into consultations Focus is on the partnership between patients, families and providers with acknowledgement of patients treatment and life goals.

Components of PCCM
Exploring both the disease and illness experience Understanding the whole person Finding common ground regarding management Incorporating prevention and health promotion

Components of PCCM
Enhancing the doctor-patient relationship Being realistic about personal limitations and issues such as the availability of time and resources

The Patient-Centred Clinical Method Six Interactive Components 1. Exploring both the disease and the illness experience: o history, physical, lab; o dimensions of illness (feelings, ideas, effects on function and expectations). 2. Understanding the whole person: o the person (e.g. life history, personal and developmental issues); o the proximal context (e.g. family, employment, social support); and o the distal context (e.g. culture, community, ecosystem). 3. Finding common ground: o problems and priorities; o goals of treatment and/or management; and

4. Incorporating prevention and health promotion: o health enhancement; o risk avoidance; o risk reduction; o early identification; and o complication reduction. 5. Enhancing the patient-health care practitioner relationship: o compassion; o power; o healing; and o self-awareness. 6. Being realistic: o teambuilding and teamwork

Patient Centred Consultation

Explore the patients main reason for the visit, concerns, and need for information. Explore patients social supports and physical environment, which may influence their health (e.g. family attitudes to healthy behaviour change) Find common ground on what the problem is and mutually agree on management.

Patient Centred Consultation

Find out whether and to what extent the person wants to participate in decisionmaking. This might be influenced by age, culture and education. Find common ground for planning ongoing management so that the health professional and the patient can agree on what should be done.

Patient Centred Consultation

Negotiate an agreed individualized written disease management plan, including specific strategies for dealing with acute symptomatic episodes. Emphasize prevention and health promotion Ensure the continuing relationship between the patient and the doctor

Questions to answer during Patient Centred Consultation

Who is the patient? What does this patient want from the doctor - Today and in the long run? How does this patient experience this illness? What are the patients ideas about the illness? What are the patients main feelings about the illness, with attention to five common responses: fear, distrust, anger, sadness, and ambivalence?

Clinical Methods
Doctors can refine their skills in ways that allow them to better attend to the person of the patient. Patient activation is an important component of patient centred interviewing. It enables the patient to take control within the consultation and promotes self management. - Often a request, tell me about yourself will suffice.

CASE STUDY TO ILLUSTRATE DCCM & PCCM

A 68-year-old male patient, who had recently been operated on for a benign stricture of the sigmoid colon presented for a routine follow-up office visit. The patient, a retired Roman Catholic priest, had very recently taken up residence in a retirement home for ageing clergy. All these facts were known to the doctor. The interaction has been reconstructed in two ways to illustrate the disease- and patient-centred methods.

CASE STUDY TO ILLUSTRATE DCCM

The Disease-Centred Method Doctor Hello Father Smith, how are you today? Patient Fineexcept for my headaches . . . Doctor . . . and your operation, how's that going? Patient Fine. Doctor Bowels working? Patient Yes.

CASE STUDY TO ILLUSTRATE DCCM

Doctor Appetite? Patient A bit poorly. Doctor Have you lost any weight? Patient No. Doctor Well, obviously your loss of appetite hasn't affected anything, so it can't be too bad? Any nausea or vomiting? Patient None.

Doctor Any pain at the operation site? Patient Not really. Doctor Are you eating the bran we recommended? Patient No. Doctor You must please stick to our recommendations. We don't want any recurrences. Patient (sighing) Yes.

CASE STUDY TO ILLUSTRATE DCCM

Doctor Good, well the operation seems to have been a success and there don't seem to be any complications. Have you any other complaints? Patient I have this headache. Doctor Is your vision affected? Patient No. Doctor Any weakness or paralysis of your limbs? Patient No.

CASE STUDY TO ILLUSTRATE DCCM

Doctor Patient Doctor Patient Doctor Patient Doctor Patient Where are your headaches? At the back of my head. Do they throb? Yes. How long do they last? About four hours What takes them away? I just lie down

Doctor How often do they come? Patient About twice a week. Doctor How long have they been there for? Patient Ever since I've been at the home. Doctor Good, well you needn't worryit can't have anything to do with your operation. They are tension headaches. Perhaps we can give you some paracetamol for it. The home you have just moved into seems to have beautiful gardens.

CASE STUDY TO ILLUSTRATE DCCM

Patient Yes. Doctor It really is good of the church to care for its elderly and it must be comforting to have company. Patient Yes. Doctor Well good. Come and see me in a month's time and we'll see how things are going. Take care.

CASE STUDY TO ILLUSTRATE PCCM

The Patient-Centred Method Doctor Hello Father Smith, how are you today? Patient Fine, except for my headaches. Doctor What about your headaches? Patient Well, I've been getting them about twice a week at the back of my head and they bother me so I can't do anything, and I have to lie down.

CASE STUDY TO ILLUSTRATE DCCM

Doctor You can't do anything? What's that like for you? Patient It's frustrating, they're interfering with the writing I want to get done and nobody seems to understand . . Doctor Understand? Patient All the other priests are so old and decrepit in that place. All they can talk about is their aches and pains. I'm ashamed to say they make me sick.

CASE STUDY TO ILLUSTRATE DCCM

Doctor Why are you ashamed? Patient Well, I shouldn't really talk that way about them, they mean no harm . . . I feel so guilty about it. Doctor What do you mean guilty? Patient I feel that my anger is unjustified, I'm so frustrated that no one understands that I wish to write. Doctor It must be frustrating . . . Patient Yes, it is and my headachesmy headaches make it worse.

CASE STUDY TO ILLUSTRATE DCCM

Doctor When did they first start? Patient Ever since I've been at the home. Doctor Why do you think that is? Patient I . . . don't know, I haven't really thought about it . . . do you think it's tension? . . . I mean the people at the home . . . is it possible? Doctor What do you think? Patient Well the whole situation at the home does trouble me.

CASE STUDY TO ILLUSTRATE DCCM

Doctor Patient Doctor you like. Patient Would you like to talk about it more? No, not now, perhaps later. Well, feel free to discuss it anytime Mmm, mmm, I will.

CASE STUDY TO ILLUSTRATE DCCM

Doctor Well, how are things going after your operation? Patient It seems okay. Doctor What do you mean, it seems okay? Patient Well I don't seem to be eating well and I can't stand that bran. In fact I have no appetite for food. Doctor What do you think that could be due to?

CASE STUDY TO ILLUSTRATE DCCM

Patient I wonder if it's due to the tension I'm feeling? Doctor Mmm, mmm. Patient I will really think about what we've said and come back to see you again. Doctor Fine, anything else today? Patient Fine, everything is fine, except I get a funny feeling on my scar. Doctor A funny feeling?

CASE STUDY TO ILLUSTRATE DCCM

Patient Yes, it seems a bit numb . . . I hope it's not serious. Doctor It's probably a little nerve that supplies the skin that was cut during the operation. Nothing to be concerned about. Patient I'm glad it's only that. I was quite worried. Doctor Anything else you'd like to discuss? Patient No, everything else is fine.

CASE STUDY TO ILLUSTRATE DCCM

Doctor Good, would you like something for your headaches? Patient Thank you, but I don't think it's necessary. Doctor I'd like to see your wound in a month's time, but we can get together earlier if you'd like to. Patient Fine, I'll be in touch, Doctor.

SUMMARY
Doctor centered (Disease centered) care Seek after own expectation to establish a biomedical or clinical diagnosis. Does not enter the patients world. Misses subtle cues in the patient doctor interaction. Patient centered clinical care has Patient guided interview Expectations of the patient are discovered Appropriate facilitative behaviour of the physician in eliciting patients feelings and fears Any conflicts in both agenda are identified and dealt with through Dr-Patient negotiation.

THANK YOU FOR LISTENING!

Acknowledgements
Some Slides- courtesy Dr O.O. Imediegwu (FMCGP) NPMCN Revision Course 2011 Patient Centred Care- Clinical Review by Monica Bensberg www.dddgp.com.au ; Accessed on 15/05/2012; 2:20pm

References
Stewart M. Towards a global definition of patient centred care. BMJ 2001; 322:444-5. Brown, J. (2004). Patient-Centred Collaborative Practice. Ottawa: Health Canada.