Patient centered approaches Flashcards
obstacle to changing behavior for the patient
resistance
obstacle to changing behavior for the provider
reactions to non-compliance
compliance definition
the extent to which the patient’s behavior matches the prescriber’s recommendation
PASSIVE
adherence definition
the extent to which a person’s behavior corresponds with agreed upon recommendations by a healthcare provider
ACTIVE
__% of patients don’t take their medication as prescribed
50-75% of patients don’t take their medication as prescribed
__ behaviors account for nearly HALF of the “premature” deaths in the US
this adds $300 billion in medical costs
modifiable health behaviors account for nearly HALF of the “premature” deaths in the US
this adds $300 billion in medical costs
modifiable health behaviors examples
smoking
poor diet
lack of exercise
alcohol
1 reason for non-adherence
forgetting
what do we want patients to comply with (5)
- taking meds
- returning for follow-up visits
- honest reporting
- listening to advice
- lifestyle alterations
4 reasons patients don’t comply with medical/health advice
- understanding
- misperception
- economics
- psychology
non-compliance: understanding
Forgetfulness, poor communication with health professionals, misunderstanding directions
non-compliance: misperception
diffrernt perspective
may be based on a perception (fear of side effects, cultural beliefs)
non-compliance: economics
cost
non-compliance: psychology
we may not even be aware of the reasons for non-compliance
why did we develop behavioral changes models?
to provide a framework for developing interventions and educating patients
way to explain health behavior
2 behavior change models
- health belief model
- transtheoretical model of change
health belief model was developed in the __ to address __
health belief model was developed in the 1950s to address public health concerns
health belief model: there is a __ that health behavior can help reduce
health belief model: there is a perceived threat that health behavior can help reduce
perceived threat = perceived __ and __
perceived threat = perceived susceptibility and severity
reducing the perceived threat has perceived __ and __
reducing the perceived threat has perceived benefits and barriers
health belief model: what is the most important predictor of health behavior
the perceived barriers
other comopnents of health belief model
Cues to Action-behavior is triggered by environmental or other events
Self-efficacy-one’s confidence to successfully modify behavior
Demographic, social, psychological factors
EXAMPLE: smoking cessation
susceptibility
I could develop heart disease
EXAMPLE: smoking cessation
severity
I could die if I develop heart disease
EXAMPLE: smoking cessation
benefits
If I stop smoking now, I may be less likely to develop heart disease
EXAMPLE: smoking cessation
barriers
quitting smoking will be hard because I’ve been smoking for 20 years and I use smoking to cope with stress
transtheoretical model of change (aka stages of change) stages
- precontemplation
- contemplation
- preparation
- action
- maintenance
pre-contemplation
- raise consciousness: increase subject’s awareness by personalizing risk of the behavior
- inform: educate subject on importance
- increase self-efficacy: increase subject’s confidence to change behavior
contemplation
- work through ambivalence: discuss pros and cons of current behavior
- build rapport: use reflective listening and open-ended questions
preparation
- plan: develop a specific plan
- problem-solve: address potential barriers and ways to overcome them
action
- reinforce coping skills: identify positive coping methods
- plan rewards for success
- determine cues that may lead to relapse
maintenance
- review strategies: continue to set and encourage goals
- self-liberation: encourage subject’s belief in self
- social support: encourage supportive relationships
stage matched intervention in FIT heart
why was there no difference in heart health in either group
hospitalization of a family member may not be a “motivational moment” for everyone
low social support is associated with non-adherence to diet, regardless of assigned group
2 models of patient care
- traditional medical model
- patient-centered care model
tenets of traditional medical model
- Doctor makes the diagnosis, prescribes medication, dietary changes, etc.
- Patient provides information about symptoms
- There is a dialogue, but the healthcare provider is the one with the knowledge
tenets of patient-centered care model
- Treats the disease AND the patient’s experience of the disease
- It’s a collaborative approach
- Healthcare professional brings expertise and empathy
how can doctors effectively listen:
let the patient talk by:
- be curious
- reflect
- use non-verbal techniques (eye contact) and body language to show you’re attentive
- allow the patient’s narrative to unfold
3 challenges of listening
- time limitations: feeling pressure
- information giving: so much to explain
- skill: knowing how to listen
best listening tool to use
OARS
OARS stands for
Open-ended
Affirmations
Reflections
Summaries
O in OARS
don’t ask for one word answers, no yes or no
A in OARS
affirmations
reinforce positive statements
empathize with difficult ones (nodding)
R in OARS
reflections
mirroring, repeating, paraphrasing
S in OARS
summaries
giving an overview of what has been said before moving to another idea
the is a different __ in how doctor’s and patients enter the room
the is a different reality in how doctor’s and patients enter the room
when the doctor enters the room, they are
confident
helpful
curious: seeking answers
when the patient enters the room, they are
vulnerable
apprenehensive
hopeful
seeking answers
different realities: conscious vs unconscious aka
external reality vs. internal reality
external reality
how we see the world
cognitive, rational sense of the world
internal reality
Unconscious, irrational. Shaped by past experience and a continuing tendency to see the present in terms of the past
Example: My smoking is my connection to my father who died when I was seven. It keeps us close.
external or internal reality
INTERNAL
Example: I smoke and I know I should stop. Everything I read says it’s bad for my health. Yet, I can’t make myself stop (ambivalence).
external or internal reality
EXTERNAL
conscious adaptation about alcohol
drinking in alcohol to excess is unhealthy
maladaptive
unconscious adaptation about alcohol
it relieves social anxiety or tension, creates playfulness and bonds
adaptive
irrationally motivated behavior is accompanied by
strong emotions
irrationally motivated behavior
- Repeated patterns of behavior can be frustrating—they often feel out of our control.
- We find ourselves in situations that are familiar but unsatisfying.
- On the surface, it seems counterintuitive that we would continue a behavior that causes so much distress.
- But this kind of pattern is informed by early experience that played an essential part of our way of being in the world. It is a part of our sense of identity.
- The irrational behavior is motivated.
self defeating behavior appears to be __, but is motivated by __ we are __ of
self defeating behavior appears to be irrational, but is motivated by needs we are unaware of
self defeating behavior still has __
self defeating behavior still has consequences
examples of self defeating behaviors
eating behaviors
getting drunk
chain smoking
helping patients understand self-defeating behaviors is an important step towards __
helping patients understand self-defeating behaviors is an important step towards self-empowerment
case-study: Mary
Mary is 15 years old and has just passed puberty. She has been gaining weight steadily for over a year and is considered overweight with a BMI of 28.5. She comes from a strong church-going family and has a good relationship with her parents. She has one younger sibling. The family physician is concerned about her weight. Her mother has not been able to help Mary gain control of her eating. Therapy is suggested.
Mary finds eating soothing. It quiets an anxiety which she feels but doesn’t understand
adaptive (conscious), maladaptive (conscious), adaptive (unconscious)
adaptive (conscious)
This is successful in dealing with underlying conflicts about separating from her family. Her need for the safety of pre-adolescence trumps her need to fit in socially, at least for the present.
adaptive (unconscious)
She is paying a heavy price for this behavior. She is subtly ostracized and unpopular with boys. As her friends talk about boys, she feels more left out and alienated. It’s unhealthy
maladative (conscious)
psychodynamic paradigm
behavior is unconsciously motivated, multi-determined, and adaptive
apparent maladaptive behavior, when we act against our own __, is coping with an __ need
apparent maladaptive behavior, when we act against our own self interest, is coping with an unconcscious need
maladative behavior maintains psychic __ and often provides safety from __, __, and __
maladative behavior maintains psychic equilibrium and often provides safety from anxiety, anger, and depression
maladaptive behavior serves to sustain our sense of
balance
__ changes may threaten maladaptive behavior and create __
one must then replace it with something (__)
lifestyle changes may threaten maladaptive behavior and create dysequilibrium
one must then replace it with something (awareness)
after behavior change, we are in __
after behavior change, we are in dysequilibrium
after behavior change, maladaptive behavior may be replaced with
an equally harmful one
example of poor symtpom substitution/replacement
Increased anxiety after smoking cessation may lead to increased food consumption which leads to weight gain (maladaptive)
example of adaptive substitution after behavior change
after smoking cessation, implementing an exercise regimen or taking a healthy cooking course (adaptive)
alex case-study
Alex, 27, is an all-around nice guy. Everybody likes him. He is always accepting and non-judgmental with his family, friends, at work and at his gym and basketball league. He has nothing bad to say about anyone. He thinks it would be sacrilegious to have bad feelings towards his family although his older brother tormented him as a youngster because Alex was a better student. In the last 6 months, since a job promotion, Alex has been suffering from insomnia which doctors have found no cause for. He awakens in the middle of the night and can’t fall back asleep. He feels he must suffer from some anxiety which he doesn’t know the cause of. But this is just a conjecture on his part.
He can’t sleep. Anxiety. Feels threatened by his new status?
maladaptive
No one will be aggressive with him as long as he stays a “nice guy” and doesn’t have to tell people what to do.
adaptive (unconscious)
He is well liked.
adaptive (conscious)
matthew case study
Matthew, a 21 year old, suffers from body image distortions. He goes to the gym every day for 2 to 3 hours to do his rigorous workout. He looks great to everyone but constantly feels uncomfortable because he believes he has too much fat on his body. He is considering liposuction as an option to help perfect his body. He would like to have a girlfriend and thinks the liposuction might be the ticket to giving him that edge with women
Spends a great deal of time trying to make his body fit an unrealistic picture
maladaptive
He is strong and muscular
adaptive (conscious)
He is able to blame his body for all that is he feels is problematic. He has a superficial solution to low self esteem and doesn’t need to examine more deeply felt issues.
adaptive (unconscious)
health practioner’s objective side of relationship
Objective science—evidence-based care
Important for determining best practices
Decision making becomes part of the professional agreement—one has the whole profession in agreement of the best way to handle a particular “diagnosis”
This is treating “disease”
subjective side of doctoring
What does it feel like to be the one responsible for another human?
What are the burdens?
What is it like to always be the one who knows the answers?
what do health professionals bring to patient encounters
Training and skill
Compassion and empathy
Ideas about how to help
Judgments
Reactions to non-compliance
Fear of pain, mortality, failure to help
Defenses-needs, fears, anxieties (similar to patients but from a less vulnerable place)
how do we feel when patients don’t listen to us?
Frustration when we are “unsuccessful” (we want to help)
Feelings of impotence—professional identity is threatened
Disappointment in self and the patient
Judgments about ourselves and patient
A need to create distance from the patient; “othering” (Shapiro article)
modern biomedical paradigm
Identification with a mentor
Scientific Objectivity vs. Subjective Emotional States
Detachment vs. Empathic connection
Control vs. Vulnerability
integrated model of patient-centerd care and traditional model
A collaborative relationship improves patient satisfaction and health behaviors
We don’t need to know the patient’s unconscious motivation to appreciate its impact
patient-centered care treats BOTH the __ and the __
patient-centered care treats BOTH the disease and the illness experienced by the individual
mental health literacy
Awareness and appreciation of the patient’s experience and capacity for change case by case
Awareness of our own needs and investments in patient improvement
Increasing empathy through these understandings
encouraging compliance and health behavior change through collaboration
summary
- Using Listening Skills, Motivational Interviewing and Cognitive Behavioral Therapy
- Acknowledging and addressing Health Literacy, e.g. providing user friendly educational materials
- Providing individualized interaction-understanding the uniqueness of each individual, i.e. appreciating the patient’s narrative
- Having/showing empathy
3 types of empathy
summary
cognitive
affective
behavioral
cognitive empathy
ability to perceive another’s point of view and be aware of one’s effect on others (e.g., “white coat effect”)
affective empathy
vicarious emotional responses to the emotions of the other. Feeling “as if” you were the other.
behavioral empathy
Ability to communicate one’s empathic response to the other and check it’s accuracy.
what makes med students become less empathetic throughout training
Fear of emotional involvement with people who are ill; of vulnerability
Our need to present ourselves as objective scientists
Frustration at the limitations of the healing professions
Fear of human frailty, including our own, which creates distance and detachment from the distressing aspects of the human condition.
reframing success: turn __ into empathy
reframing success: turn judgment into empathy
5 ways to enhance interactions with patients
- Understanding our own motivation and our impact on the patient
- Starting where the patient is through active listening, suspending judgments, using tools etc.
- Promoting self-efficacy—through collaboration
- Encouraging self-acceptance—patient leaves the encounter feeling accepted by the practitioner
- Ongoing relationship- feeling understood, the patient will feel free to return for follow up
