Patient Centered Care Workshop:

Patient Centered Care Workshop:
Providing Quality Health Care to a Diverse Population This “patient center care” workshop is about an approach to providing quality healthcare to a diverse patient population. The Patient centered care approach takes into account three perspectives – the patient, the physician and society. Practicing the skills of patient centered care should help you 1) become a more culturally competent physician and avoid the trap of stereotyping individuals 2) assure that you will take into account socioeconomic barriers and disparities in health care that affect your patients Overall, you will find the patient centered care approach will help you care for patients from diverse backgrounds and will help assure quality care plans for all of your patients. [Note: We have included an acknowledgement to ourselves as authors – as we think its important that others recognize that medical schools across the country are focusing on this issue and that as professionals we recognize our colleagues contributions. You will note that we have left the names of the actual presenters on these slides – but you will want to list your own presenters]. Acknowledgement: This Workshop was Originally Developed by Faculty and Students at the Medical College of Wisconsin.

Patient Centered Care Rationale:
There is a nationally recognized need to address social and cultural diversity and disparities in health care LCME Standards AAMC Senior Graduation Questionnaire Data This workshop provides skills and process to Address Social and Cultural Diversity Address Ethnic and Socioeconomic Barriers/Disparities in Health Care. . . and Achieve excellence in patient care The medical education rationale for this Patient Center Care workshop is to address a nationally recognized need to improve the quality and time devoted to teaching of social and cultural diversity, and disparities in health care. Addressing social and cultural diversity is a standard set by the LCME, (Liaison Committee for Medical Education) of the AAMC, which is the medical school accreditation body. This need is also evident in the AAMC Sr. graduation questionnaire data from 2006. This workshop addresses these key issues. It is our belief that the patient centered approach ultimately achieves excellence in patient care for all of our patients from every walk of life.

AAMC Sr. GQ 2006 Population Medicine
% “Inadequate Time” The AAMC senior graduation questionnaire from 2006 suggests that one fourth to one third of students reported inadequate curricular time spent in public and community health and the role of community health and social service agencies. Note: This is the national data – you may want to insert your own school’s local AAMC data and/or select other items.

AAMC Sr. GQ 2006 Population Medicine
% Inadequate Almost one fourth to 30% of graduating US medical students in 2006 felt there was inadequate time spent addressing, culturally appropriate care for diverse populations, health disparities and health determinants. It is our hope that this workshop will better prepare you to address each of these issues. Note: You may want to include data from your own school’s local AAMC data, rather than the national data and/or selected other items.

LCME Standard ED-20. The curriculum must prepare students for their role in addressing the medical consequences of common societal problems… There are three medical school accreditation standards that are addressed by this workshop. The first is educational standard 20 that suggests that the curriculum must prepare students for their role of addressing the medical consequences of common societal problems.

LCME Standard ED-21. The faculty & students must demonstrate an understanding of the manner in which people of diverse cultures and belief systems perceive health and illness and respond to various symptoms, diseases, and treatments. Educational standard number 21 suggests that faculty and students must demonstrate an understanding of the manner which people of diverse culture and belief systems perceive health and illness and respond to various symptoms, diseases, and treatments.

LCME Standard ED-22. Medical students must learn to recognize and appropriately address gender and cultural biases in themselves and others, and in the process of health care delivery. And finally, educational standard number 22, suggests medical students must learn to recognize and appropriately address gender and biases in themselves and others and in the process of healthcare delivery.

Traditional MD Training: The Biomedical Model Assumption
Health/Disease is explained by some measurable biological variable Leaves little room for social, psychological, behavioral dimensions of illness Patient's views re: healing/health care Poverty Racism, Sexism, Ageism, “…isms” Standard medical training traditionally emphasized a biomedical approach. Especially in the first two years of medical school you learn that health and disease is explained by some measurable biological variable or pathophysiologic process. This leaves very little room for the social psychological or behavioral dimensions of illness. The biomedical model tends to diminish the patient’s views or the patient’s “explanatory model” of health. The patient’s explanatory model is the patients view or explanation of their understanding of their health, illness or healing. Additionally, there is generally little consideration of the influence of poverty, racism, sexism, ageism, and the other “isms” on how it influences health.

Patient Centered Care: The Three Perspective Approach
Identify meaning of illness (Kleinman Questions) Social Context ROS Physician Society Patient Centered Care Plan (that will Optimize Patient Outcomes) As clinicians, our bottom line goal is to optimize patient outcomes through effective treatment plans for all of our patients including those from socially and culturally diverse backgrounds. With this goal in mind, we will challenge you with what is intended to be provocative background information and clinical tools. We will also practice using these clinical tools. The patient centered approach looks at your patient encounters from three perspectives: The patient perspective, including eliciting from the patient what an illness means to them -- using Kleinman’s questions and the social context review of systems as clinical tools, The physician perspective and understanding of their own biases and beliefs, and The social and societal factors that could influence the health of our patient.

Patient Centered Care: An Example
The patient is a 35-year old male with BP 176/100 BP 2 months previous 170/100 Biomedical Model - HTN Per evidence-based guidelines, you Rx hydrochlorothiazide (HCTZ) To illustrate the three perspectives of Patient Centered Care, we will start with a simple, but real example. You are seeing a patient who is a 35 year old male with a blood pressure of 176/100. His blood pressure the two previous months were in the 170 to 100 range. The biomedical model of hypertension for evidence-based guidelines would suggest that we could use as a general principle, initiate hydrochlorothiazide.

Understanding the Disease Biomedical Model “It”
Where does it hurt When did it start? How long does it last? What makes it better or worse Write Rx per EBM protocol From the biomedical perspective, we would ask “disease orientated questions” to understand the disease (but not necessarily our patient). The biomedical perspective asks questions with the word “it.” For instance, where does it hurt, when did it start, how long does it last and what makes it better or worse. So we diagnose and treat and write prescriptions per an evidence-based medicine protocol.

Patient Centered Care: An Example
Two months later, what are the outcomes? Some patients do fine – others do not. There is good evidence that patient satisfaction and compliance are closely related to the effectiveness of your communication and doctor/patient relationship. From the physicians perspective BP is controlled with medication due to excellent evidence that it will prevent heart attach and stroke. If we consider the patients “explanatory model” for hypertension, we may discover that their concept is that hypertension is an episodic problem related to tension and stress. From the patients perspective, blood pressure treatment would perhaps require taking medication only as necessary. If your patient takes medication only when stressed, your treatment will likely be unsuccessful especially if the medication has side effects. There may be social or societal issues that can affect the success of your treatment plan. Perhaps the patient can not access a pharmacy on a monthly basis or does not have the resources to purchase the prescription. You need to understand your patient and asking the right questions to improve health care outcomes.

Understanding the Illness: The Patient’s Perspective
Biomedical Model of Care Where does it hurt When did it start? How long does it last? What makes it better or worse? Explanatory Model of Care/Meaning of Illness What are YOU most concerned about How does it disrupt YOUR life? What do YOU think it is? How do YOU think I can help you? You need to understand your patient and asking the right questions can help to improve health care outcomes. Using the explanatory model of care, we take into account the patient meaning of illness. In contrast to the biomedical model questions with “it”, the explanatory model of care questions more commonly use the word “you.” For instance, what are you most concerned about, how does the condition disrupt your life, what do you think your condition is due to and how do you think I can help you? Improved Health Care Outcomes

The Three Perspectives of Patient Centered Care: The Patient, The Physician, Society
Meaning of Illness Social Context ROS Impact on Patient Impact on Others Support Systems Resources Control of Environment Literacy/Language So again, our framework as outlined in the Carrillo article is to consider the patient’s perspective, (e.g. patient believes is the cause of their illness, or other beliefs or fears). In addition, it is important to consider the impact of the patients social context or circumstance that could affect their health. These concepts are nicely outlined in the article by Carrillo. Carrillo JE, Green AR, Betancourt JR. Cross-Cultural Primary Care: A Patient-Based Approach. Ann Intern Med 1999;130:

Meaning of Illness Social Context ROS PHYSICIAN PERSPECTIVES Biomedical model Biases EBM Values/Beliefs Now consider the perspective of the physician. The physician’s perspective may or may not overlap with that of the patients. For example, your patient may not “buy in” to the biomedical model; in addition, physicians have their own biases and beliefs that they need to be aware of, as they might bring this into the doctor/patient relationship that may affect our patient care outcome.

Meaning of Illness Social Context ROS PHYSICIAN PERSPECTIVES Biomedical model Biases EBM Values/Beliefs The best patient centered care plan that emerges is negotiated where the physician and patient perspectives intersect. It takes excellent interview skills and listening skills to determine where these perspectives intersect. You need to be careful not to assume the doctor and patient are from similar social and cultural backgrounds. PATIENT CENTERED CARE PLAN

Poverty; Literacy; Culture Underinsured …ISM’s (racism, sexism) Now, if one overlays the societal issues, the challenge of developing a good care plan becomes larger.

Patient Centered Care Plan
The Three Perspectives of Patient Centered Care: The Patient, The Physician, Society PATIENT PERSPECTIVE PHYSICIAN PERSPECTIVE SOCIETY PERSPECTIVE So developing a quality patient care plan requires consideration of all three perspectives; the patient, the physician and the society. Patient Centered Care Plan

Identify meaning of illness to patient (Kleinman Questions) Social Context (ROS) Physician Society Be Realistic Patient Centered Care Plan (that will Optimize Patient Outcomes) The optimal outcome requires a dose of realism! In our workshops today, we will practice looking at your patient encounters from three perspectives in order to provide the best patient care. Finally, we need to be realistic to optimize a treatment plan. It is important to find the common ground that maintains your commitment to excellence while respecting your patients values and beliefs.

Objectives Patient: Apply the Kleinman questions to elicit each patient’s perspectives on health, disease, illness, and treatment Apply the Social Context ROS So, the objectives for this workshop is to consider our health care encounters from the patients perspective by applying two “tools”, the Kleinman questions and the social context review systems. The Kleinman questions are simple direct questions that elicit each patients perspective on health, disease, illness and treatment. The social context review systems is a systematic approach to asking questions related to the patients social circumstance.

Objectives Physician: Incorporate a patient centered approach in the daily care of patients Society: Identify ethnic and socio-economic barriers and disparities in health care. From the physician perspective, incorporate a patient-centered approach in your daily care of patients. This requires some self evaluation and self critique. This workshop is an opportunity for you to consider and think about these issues. Finally, you will consider the societal perspective by identifying ethnic and socioeconomic barriers and disparities in health care that may impact a health care encounter as to provide quality care to socially and culturally diverse populations.

Patient Centered Care Today’s Agenda:
Background/Objectives Critical Incident “America in Black & White” - Nightline Video “What I Have Learned About People and Poverty” Frame: Patient Centered Care Plan Eliciting Patient Values/Beliefs Social Context ROS Small Group Directions Small Group Discussion Evaluation Today’s agenda: We have just finished reviewing the background and objectives for the workshops. In a moment, we will have each of you write down one of your “own experiences,” or “critical incidence” that have occurred in the past six months that will help you begin to actively think about patient-centered care. We will then have you watch “America in Black & White” a compelling Ted Koppel Nightline video based on the New England Journal of Medicine article that you read preparing for this workshop. Mr. Bill Solberg will present “What I Have Learned About People and Poverty.” We will then have a thought provoking presentation introducing you to the clinical tools you will be applying during this workshop including the Kleinman questions for eliciting patient values, beliefs and the social context review system, systematically looking at the patient’s social circumstance. Finally, we will move to our small group discussions where we use patient care vignettes and our critical incidence to practice applying some of these principles.

Collaborative Working Group Members at MCW
Elizabeth Berdan, M3 Douglas Bower, MD – Fam & Com Med J. Sonya Haw, M2 Gunnar Larson, MD – Psych & Beh Sci Sajani Tipnis, MD - Pediatrics Staci Young, MS – Fam & Com Med Travis Webb, MD – Trauma Surgery Sheri Galewski – Educ Services Deborah Simpson, PhD – Educ Services We’ve adapted the materials from the Medical College of Wisconsin for use in this session and want to acknowledge our colleagues. [Note: You may also want to include a slide specific to your own session leaders/authoring team].

Critical Incident Identify a recent patient for whom it was difficult to achieve excellence from your perspective as a physician. Select patient who evoked a STRONG emotional reaction Anger, frustration, annoyance, exasperation You will now be given ten minutes to do a “writing blitz” on a patient care on one of your own patient care critical care incidence. We will ask you to identify a recent patient for whom it was difficult for you to achieve excellence from your perspective as a physician. Please select a patient who has evoked a strong emotional reaction such as anger, frustration, annoyance, exasperation.

Critical Incident Select a Patient
Patient should NOT be difficult due to their medical problem, but who was challenging for you because of the patient's Expectations of you and/or health care system Emotional state Current social situation Language, literacy Beliefs/values Other (e.g., ethnicity, race, country of origin, age) Your patient should not be difficult due to their medical problem, but a patient who is challenging to you because of the patient’s expectations of you with the health care system. Their emotional state or current social circumstance barriers related to language, literacy, or differences in beliefs and values or issues related to ethnicity, race, country of origin, age, etc.

Critical Incident For your selected patient
Briefly describe The patient Context/setting in which incident occurred What evidence/incident/behavior evoked your reaction Your approach/interaction with patient Describe why you think THIS patient/patient interactions was difficult-evoked a strong emotional response We have provided a form which is a format for you to describe your critical incident. You will briefly describe the patient’s situation, the context or setting and which incident occurred and what evidence incidence or behavior evoked your reaction and finally your approach or interaction with this patient. We will also ask you to describe why you think this patient or patient interaction was difficult or evoke such a strong emotional response. Keep your incident - will be used/turned in during small group

Today’s Agenda Background/Objectives Critical Incident
“America in Black & White” - Nightline Video “What I Have Learned About People and Poverty” Frame: Patient-Centered Care Plan Eliciting Patient Values/Beliefs Social Context ROS Small Group Directions Small Group Discussion Evaluation We will continue our presentation by introducing you to a Nightline video entitled “America in Black and White” One of the main goals of our workshop is to expose disparities in health care. In addition to increasing awareness we would like to also provide a framework to avoid these exposed disparities.

Physician and Society America in Black & White
Disparities in Health Care Travis Webb, MD

Preparatory Readings Carrillo JE, Green AR, Betancourt JR. Cross-Cultural Primary Care: A Patient-Based Approach. Ann Intern Med 1999;130: Schulman KA, Berlin JA, Harless W, Kerner JF, et al., The effect of race and sex on physicians’ recommendations for cardiac catherterization. NEJM 1999;340: You were given 2 articles in order to help you prepare for today’s presentations and discussions. The Carrilo article entitled “Cross Cultural Primary Care: A Patient-Based Approach” describes some of the background as to how to use a patient centered care approach. It also exposes you to the social context review of systems. The New England Journal of Medicine article entitled “ The effect of race and sex on physicians’ recommendations for cardiac catheterization” by Schulman led to nation wide recognition of disparities of health care in regards to cardiac catheterization when examined between race and sex.

Nightline Video NEJM Cardiac Cath
February 24, 1999 Nightline segment called "America in Black and White: Doctors and Patients." Consider differences in health care from perspectives of Patient Physician Society On February 24, 1999 a Nightline segment called “America in Black and White: Doctors and Patients” brought to light multiple disparities in health care for patients of varying race and socioeconomic backgrounds. As you watch this video, you should consider differences in health care from the perspective of the patient, physician and society as a whole.

Begin Video A prompt for beginning the Nightline Video if you have obtained this segment.

“America in Black & White” - Nightline Video “What I Have Learned About People and Poverty” Frame: Patient-Centered Care Plan Eliciting Patient Values/Beliefs Social Context ROS Small Group Directions Small Group Discussion Evaluation Next on our agenda today is a discussion about personal experience and how social and economic factors influence health care.

Social and Economic Factors that Influence Health
Note: Originally we invited a community social worker to present the content of this section. Subsequently we have invited one of our co-authors to present, as she was very knowledgeable in this area. Its purpose is to speak from evidence and personal experience to make the issues of social and economic factors that influence health, real to the learners. The next four slides provide speaker content. Staci Young, MS Department of Family and Community Medicine Center for Healthy Communities

Why Does SES Influence Health?
Health behaviors Health care quality and access Social support networks and contacts Acute and chronic stressors Neighborhood/community context SES is a general tem meant to represent the broad range of socioeconomic resources on which people are hierarchically stratified. Examples of SES include income, assets, educational level and occupation. SES affects one’s health status through various avenues, including social support and neighborhood context. Health status has many contributing factors, both biological and social. Biological causes include family history of illness, individual behaviors and lifestyle and measures such as body mass index and diet. These are risk factors that are relatively proximate causes of disease. It is important to note that health care access has different variables. Access is not just insurance status. It is based on the availability of services, affordability, acceptability, and accessibility. Services that do not fit these requirements are not accessible to patients. Social factors (e.g. socioeconomic status, education, neighborhood conditions) are more distal causes of disease and receive less attention. The use of individual level risk factors and locating the responsibility for cause and cure of health conditions within individual behavior provides a limited understanding of one’s health status. Rather, it’s beneficial to pay greater attention to the basic social conditions for maximum health reform. The social environments that lack resources such as food, housing, strong social networks, employment and other services are those at highest risk for serious illness and even death. Those of lower SES experience acute and chronic stressors that affect health. This can be due to life changes associated with social and/or cultural mobility. Another source may be specific life events. Susceptibility could also be influenced by how one copes with stress in everyday life. For example, smoking as a coping mechanism is linked to nearly all causes of morbidity and mortality. There are links between community social characteristics and variations in individual-level health such that even when individual attributes and behaviors are taken into account, there is evidence of direct risk factors linked to environmental context.

SES - an Individual and Community Phenomenon
How is SES experienced at the community level? Amount of real and perceived crime Access to medical services Affordability and quality of food Safe child care Quality and affordability of education Quality and affordability of housing Quality and quantity of municipal services SES is not just experienced at the individual level. SES affects entire communities. Those of lower SES have poorer access to quality education, housing, and municipal services that may ultimately affect health. Housing operates at several levels to influence health status. As a primary need in the hierarchy of needs, housing is fundamental. The quality and availability of affordable housing has become a social justice issue that adversely affects health. While substandard housing has long been linked to infectious diseases such as tuberculosis, cholera and respiratory infections, it is also linked to an increased risk of chronic illness. For example, damp, cold and moldy housing is linked to asthma and chronic respiratory illness, even after controlling for social class, income, smoking and unemployment. Substandard housing also includes pest infestations such as cockroaches and mice, both of which contribute to asthma hospitalizations among inner city children. Poor housing structure can increase injury; this includes exposed heating sources, poorly designed stairs with low lighting and unprotected upper-story windows. Poor housing may increase social isolation if occupants limit their guests or if common spaces are lacking (as in high rise buildings). These are psychosocial stressors that can lead to mental health problems. Food security is an issue for those with lower SES. There is lesser access to quality food stores with the fresh produce that is often required as part of a healthy lifestyle. The amount of real and perceived crime in a given community may affect residents’ ability to exercise in public spaces.

What Can a Physician Do? Multiple aspects of economic and social life affect health status. Physicians can effectively address these issues in broad advocacy, policy, and systems interventions, and in one-on-one patient encounters. Access and other SES factors have an extremely strong influence on health outcomes, but what can a physician do about it? Certainly s/he can work to improve access to care, both in general, and in her / his own practice (e.g., clinic hours open, transportation options, help with insurance coverage specifics and with signing up for safety net coverage, etc.). In addition, much more can be done at both the individual level and at the level of community and policy. For example: Individual level: Be active in community-wide initiatives to promote and improve health Coordinate services for individual patients Provide care to medically indigent Keep your patients’ social and economic contexts in mind during each visit, e.g., healthier diet may be difficult for folks lacking money to buy the food, or for whom a certain diet (diabetic, low salt, etc) doesn’t fit into their cultural norms exercise may be difficult for folks working long hours or inflexible jobs follow-up appointments may be difficult for folks working long hours or inflexible jobs, or who have child-care issues medication adherence may be difficult for folks who must buy meds out of pocket Note: It is critical to address each patient individually rather than to make assumptions about based on their social and economic context. For example, avoid the mistake that some people make who assume that a poorer patient is going to be non-compliant, stupid, drug-addicted, or otherwise engaging in health risk behaviors. It is essential to approach each patient individually and without prejudice. Community / population level: Advocate among peers for improved access to their practices Advocate for better laws, regulations, and policies (e.g., Rx drug coverage, patient’s bill of rights, eligibility requirements for aid, insurance company regulations) Inform policies and procedures (comments, committees, legislation) Support community-based services -- you can do this in your office setting by sharing space with other services, or having a social worker on staff who can facilitate patients’ accessing community-based services.

“America in Black & White” - Nightline Video “What I Have Learned About People and Poverty” Frame: Patient-Centered Care Plan Eliciting Patient Values/Beliefs Social Context ROS Small Group Directions Small Group Discussion Evaluation Next we would like to more thoroughly discuss how to implement a patient centered care plan.

Identify meaning of illness to patient (Kleinman Questions) Social Context (ROS) Physician Society Be Realistic Patient Centered Care Plan (that will Optimize Patient Outcomes) Our goal in using a patient centered care approach is to recognize that there are barriers to good health care. We need to recognize that race, physician bias, socioeconomic barriers all impact the final negotiated care plan. Finally developing a realistic plan with the patient will lead to improved outcomes.

Meaning of Illness The first step in using a patient centered care approach is to determine the patient’s mindset. The physician must be able to determine what the patient brings to the table as is evident by their insight into their illness.

Patient Centered Interviewing Skills Eliciting Patient's Values
Culture plays an integral role in health and illness. It is by knowing how and when to ask questions that enables a physician to more completely understand their patients. There is no one set of questions to ask for every patient. There is no one set of beliefs about a culture to know. Becoming a patient centered physician begins with identifying and understanding your own values, then eliciting the patient’s values in terms of their healthcare. [Note: You may want to change the names of the presenters – Ms. Berdan was an active member of our planning group and we thought it was very important that her colleagues see one of “their own” presenting.] Elizabeth Berdan, M3 Gunnar Larson, MD

Self-Awareness & Humility
Examine own values, beliefs, and traditions Explore ways in which health, illness, & healing are understood by different people Set aside your own bias in order to deliver effective care to diverse populations Common to many sources, the suggested first step to becoming a patient-centered physician begins with introspective self analysis. Before a healthcare professional is able to be sensitive to the experiences of others, first we must evaluate and identify own values, beliefs and traditions. This self-analysis includes our assumptions about hierarchy, authority, privacy, family, gender roles, professional expertise, communication styles, decision making, education, social class, sexual orientation, disability, obesity. An important reason for this exercise of introspection will enable us to provide better care to our patients by understanding our patient’s obstacles to quality care. For example: How do patients view health and illness and how does it differ from our views? The only way we might understand that our ideas are different from our patient’s ideas may be through indirect methods, such as failing to follow physician guidance – or what we might call COMPLIANCE. Note: Be mindful of the word choice used with patients: compliance carries an implicit assumption that the physician has greater knowledge and authority than the patient.

Patient Centered Physician
When the patient is the center of your healthcare services, you do focus on differences. Different perspectives regarding hierarchy, authority, privacy, family, gender roles, professional expertise, communication styles, decision making, education, social class, sexual orientation, disability and obesity. If the illness or disease is the central focus of your healthcare, the patient-physician relationship is in danger of becoming a one-sided relationship. Remember as physicians we also contribute to the dynamic patient-physician relationship with our history and background. Physician

Kleinman’s Questions & The Patient Centered Method
Offers structure to the patient-physician interview An excellent way to begin building your treatment agreement Kleinman’s questions are often referred to as the explanatory model A patient centered physician focuses not only on the disease and treatment, but also on the patient’s concept of what’s wrong with them, their feelings about the illness, the impact on their lives, and expectations on what should be done. Kleinman’s questions allow the patient to explain their perspective. Kleinman A. Eisenberg L, Good B. Culture, illness, and care: clinical lessons from anthropologic and cross-cultural research. Ann Intern Med. 1978;88:251-8.

Kleinman Questions What do you think has caused your problem?
Why do you think it started when it did? What do you think your sickness does to you? How does it work? How severe is your sickness? Will it have a short or long course? What kind of treatment should you receive? Use of these questions increases the likelihood that the care provided is congruent with the patient’s expectations. A review of the eight Kleinman questions are listed on this slide and the next slide for the audience's orientation.

Kleinman Questions Continued
What are the most important results you hope to receive from this treatment? What are the chief problems your sickness has caused for you? What do you fear most about your sickness?

Challenge Your Assumptions
Ask your patient questions… Assuming you know the answers can lead to errors/misjudgments limiting quality of care It is when we assume we know what our patients are concerned with that we loose our patient-doctor connection. Remembering that our background may be significantly different from our patient’s history allows us to recognize the appropriate questions to ask in order to gain accurate information to avoid less than excellent quality healthcare.

Money Questions! Establishes that you are interested in your patient’s
1) What do you think has caused your problem? 2) Why do you think it started when it did? Establishes that you are interested in your patient’s Values Time Ideas The first two Kleinman questions allow you to understand the patient’s insight into their own health, illness and disease is while establishing a trustful relationship. As students when you know the H&P you look like you know what you are doing, even if you don’t! As beginning clinicians we primarily investigate the information available and attempt to categorize the information for our attending. By asking the right questions in the right way your information yield increases significantly. Much of the time, the patient will tell you exactly what is wrong with them. You just have to interpret the information obtained.

Patient-Doctor Connection
Allows you to gauge your patients insight into their health concerns. Helps to guide patient education on treatment and prevention. What do you think your sickness does to you? How does it work? How severe is your sickness? Will it have a short or long course? Kleinman questions three and four allow you to understand what your patients are thinking in terms of disease, illness and health. This helps to guide patient education for treatment and recovery.

The Agreement What do they want to improve? Are we on that same page?
Where is our common ground in defining your treatment? What kind of treatment should you receive? What are the most important results you hope to receive from this treatment? Kleinman questions five and six allow the physician to establish the reason for the visit. For example, a patient may see a physician for a painful toe, but the physician focuses on their poorly controlled hypertension. If the patient’s initial request for pain relief is ignored this hinders the development of a trustful patient-physician relationship. However, if the patient’s concerns are addressed first, a trustful environment may be created in order to help the patient control their hypertension.

Their Goal Is Your Goal Help the patient to be the best they can be with THEIR self care efforts Don’t impose YOUR idealized treatment goals What are the chief problems your sickness has caused for you? What do you fear most about your sickness? The Kleinman questions provide clinicians with a format to understand the goals and limitations a patient has for their healthcare and lifestyle. To be an effective physician it is important to remember to help the patient to be the best they can be with their resources, life experiences and goals.

Patient Resources Hook your patient up!
Referrals to PT, nutritionist, pain clinic, etc. Group support Can they read well? Will they read your handouts? Do they have secure housing? Do they have transportation to your office? Every person in the healthcare system are patient advocates. Part of being a patient centered physician is learning about the community you practice within and what resources are available to aid them in their healthcare. Linking patients to community resources may be a powerful motivator towards better health. A network of support empowers your patients to act in their best interests.

That Doctor Magic That special way to “treat” that special population (homeless, IV drug users, non-English speakers, the list goes on!) Kleinman questions may aid you, but it’s your approach that means just as much. They need to know you are on their side and that you won’t abandon them if something goes wrong. Patient center care allows you to treat EACH patient as unique and special. My ability as a physician to learn about all of the different cultures, ethnicities, religions, gender, age and every other way may patients may differ is limited. While there is evidence that we, as physicians, must take into account in treating patients based on various demographic and genetic variables, by treating each patient with respect and learning “their story” we can truly provide patient centered care. How do we learn about our patients? There are specific questions we can ask (Kleinman) to help us demonstrate respect for our patients and gather data to provide the best patient care. The approach of the physician is just as important as the words a physician may speak to a patient. The strength of the patient-physician relationship is the most important foundation on which to build quality patient care.

Patient Centered Dynamic
Patient specific – DON’T ASSUME – not racially, ethnically or class specific Requires the same commitment as anything else reading practice self-evaluation A successful patient-centered physician is flexible in how they relate to and manage patients. As in every area of medicine, a commitment to developing the skills of a patient centered physician requires reading the relevant literature, practice and continued self-evaluation.

Social Context ROS Travis Webb, MD
An integral part of understanding a patient’s insight is to examine the social context review of systems.

Meaning of Illness Social Context ROS The concept of a social context review of systems has been well documented by Carrillo. Carrillo JE, Green AR, Betancourt JR. Cross-Cultural Primary Care: A Patient-Based Approach. Ann Intern Med 1999;130:

Meaning of Illness Social Context ROS Impact on Patient Impact on Others Support Systems Resources Control of Environment Literacy/Language The Social Context Review of Systems reviews the impact of the illness on the patient as well as other care providers and family members. Support systems and resources are also addressed during this evaluation. A patient’s ability to control their environment is likewise extremely important in understanding how a care plan will be able to enacted. Finally understanding a patient’s ability to read and understand instructions is important to a successful negotiated care plan. Carrillo JE, Green AR, Betancourt JR. Cross-Cultural Primary Care: A Patient-Based Approach. Ann Intern Med 1999;130:

Meaning of Illness Social Context ROS PHYSICIAN PERSPECTIVES Biomedical model Biases EBM Values/Beliefs Again we must consider the prospective of the physician. The physician must realize that he or she brings their own set of biases that will effect the interaction of the patient as well as the overall patient care outcome

Poverty; Literacy; Culture Underinsured …ISM’s (racism, sexism) Again we must consider the prospective of the physician. The physician must realize that he or she brings their own set of biases that will effect the interaction of the patient as well as the overall patient care outcome.

The Three Perspectives of Patient Centered Care: The Patient, The Physician, Society PATIENT PERSPECTIVE PHYSICIAN PERSPECTIVE SOCIETY PERSPECTIVE Therefore in the end you will have overlapping agreement between the patient, physician and society which will allow you to improve your patient’s outcomes due to a better negotiated agreement for healthcare. Patient Centered Care Plan

Today’s Agenda Background, Objectives, Agenda Critical Incident
“America in Black & White” - Nightline Video “What I Have Learned About People and Poverty” - William Solberg, LCSW Frame: Patient-Centered Care Plan Eliciting Patient Values/Beliefs - E Berdan, M3 Social Context ROS – T Webb, MD Small Group Directions + Travel MCW Room assignments

“America in Black & White” - Nightline Video “What I Have Learned About People and Poverty” Frame: Patient-Centered Care Plan Eliciting Patient Values/Beliefs Social Context ROS Small Group Directions Small Group Discussion Evaluation Note: This is transition slide. The workshop leaders will need to give a brief overview of the small group process. Then students and faculty facilitators will need to be directed to their small group discussion room locations.

Small Group Directions
Douglas J. Bower, M.D.

Patient Center Care Application
Cases 28 yo pregnant 55 yo male with Chest Pain in ED 20 yo with infection 75 yo Breast Cancer + Your Critical Incident In your small group discussion sections, you will have the opportunity to apply the patient centered care model, with the goal of developing a care plan to improve your patients health. Your small group leaders will have four paper cases to provide the basis for discussion and application of patient centered care principles. In addition, your small group leaders will use one or several of your own critical incidence as the basis for discussion.

Small Groups: Care Plan
Review each case from perspective of: Patient (Values + Social Context ROS) Physician Society Goal: Develop a patient-centered care plan that is realistic and will achieve best health care outcomes Your small group leader will have you review each case from the three perspectives we have discussed: the patient, the physician and society. The goal of each case will be to develop a patient centered care plan that is realistic and will achieve best health care outcomes.

TWO FACILITATORS PER GROUP
Small Group Assignments: students per small group, + 2 facilitators TWO FACILITATORS PER GROUP Physician Professionals with backgrounds in: Theology Psychology Public Health Social Science Community Health Each small group will have students and two facilitators. One facilitator will be a physician. The other facilitator will be a professional from the community that regularly deals with health care issues. They have backgrounds in a variety of fields including theology, psychology, public health, social science and community health.

The Three Perspectives of Patient Centered Care: The Patient, The Physician, Society PATIENT PERSPECTIVE PHYSICIAN PERSPECTIVE SOCIETY PERSPECTIVE Note: Leave this final slide up as students and facilitators travel to their small groups. You can give specific instructions regarding small group locations at this time. Patient Centered Care Plan

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