Transcript The number of Physicians per 100000 People in European

Contextual Care
Class 2, 12.09.2011
Atatürk University Medical Faculty
Zekeriya Aktürk, Prof.
[email protected] http://aile.atauni.edu.tr
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Aim-Objectives
• At the end of this lecture the participants should
have information about the individualized and
contextual care principles in family medicine
• At the end of the lecture, participants should
reach the following objectives:
– Explain the importance of contextual care in family
practice
– Mention methods in evaluating family functioning
– Discuss the effect of family atmosphere in health care
provision
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One Case
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Jackie Anderson, 43 y ♀
Salesperson since 2 years
Burning abdominal pain – 2 months
Antacids – no benefit
Pain improves by eating, gets worse by spices
No weight loss
No GI bleeding
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Work schedule very hectic
Couldn’t work 3 days beause of pain
Dislikes her job
Mother Alzheimer – receiving home care
Parents divorced – no contact with father
Drinks 3-4 glass wine/day
Family history of alcoholoism
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• Physical exam normal
• Doctor asks to discontinue alcohol for 2
weeks ad do a barium x-ray
• Liver transaminases slightly increased
• Jackie returns to doctors office to discuss
the tests
• Her abdominal pain is markedly improved
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What should be the approach for
this patient?
• Biomedical:
– Gastritis precipitated by alcohol
– Antacid therapy
– Alcohol counseling
• Biopsychosocial:
– Adding job and family stress
• Family systems model
– Explore family of origin issues
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The Contextual Model
• Help the patient to define
– Which of the contexts to explore
– And in what order
• Explore the meaning of the symptoms in her
life
• Define the role of the physician
• Develop a treatment model that is most
consistent with the role of the physician
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The Context of Patient and
Physician
• The family context
– What is the structure of the family?
• Who does the patient define as the other members?
• What is the relationship of individuals?
• What is the relationship of patient with others?
– How does this family function?
• Food, shelter, clothing..
• Responsibility to children
• Cultural values of society
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How to assess family function?
• Family circle
• Family Apgar
• FACES
http://www.facesiv.com/
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http://etd.lib.ttu.edu/theses/available/etd-11252008-31295011191763/unrestricted/31295011191763.pdf
Contextual Errors
• A contextual error occurs when a physician
overlooks elements of a patient’s
environment or behavior that are essential
to planning appropriate care. In contrast to
biomedical errors, which are not patientspecific, contextual errors represent a
failure to individualize care.
Weiner SJ, Schwartz A, Weaver F, Goldberg J, Yudkowsky R, Sharma G. Contextual Errors and Failures in
Individualizing Patient Care: A Multicenter Study. Annals of Internal Medicine 2010;153(2):69-77
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• Physicians probed fewer contextual than
biomedical hints.
• They provided error-free care more often in
the uncomplicated encounters (73%) than in
the biomedically (38%), contextually
(22%), or biomedically and contextually
(9%) complicated encounters.
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• Every individual has his/ger own health
resources and risks related with the
environment
• Our medical approaches will not be
successfull unless we take into account the
context of the patient
• There is no sense in advising a patient in
powerty to eat a diet high in proteins and
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fiber!
Smith PH, Murray CE, Coker AL. The Coping Window: A Contextual Understanding of the Methods16
Women
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Use to Cope With Battering. Violence and Victims, Volume 25, Number 1, 2010.
• “Well, yes, you are taking the pills, Arden.
But how are you taking the pills?”
• “I take the blue pill on one day, the white
one the next, and the pink pill on the third
day.”
• “Arden . . . why on earth would you do
that?”
• “It’s like you’ve been preaching to me,
Doc: Moderation, moderation.”
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• In the solemn privacy of the examination room, I have
asked my patients all manner of intimate questions—
about their sexual orientation; illicit drug use; income
and the affordability of medications; marital infidelity;
the possibility of felonious behavior, as it might have
related to guilt and depression; or of wifebeating and
the abuse of children— but I have never in my
recollection asked a patient whether he could read or
write.
• Yet 1% of Americans are illiterate, and 30% to 40%
are estimated to have inadequate or marginal health
literacy
LaCombe MA
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• It is estimated that 50% of Americans read
so poorly that they cannot properly read
prescription drug labels and 3 of 4 people
on welfare cannot read at all
LaCombe MA. Contextual Errors. Annals of Internal Medicine 2010;153(2):126-127
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Also the availability of health
resources are not same in all
regions
• Küçük şehirlerde, doğu ve güneydoğuda ve
kırsal alanda sağlık personeli sayısı ve
niteliği diğer bölgelere göre daha azdır.
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Comparison of EU Average, WHO European Region Average and
Turkey for the Number of Physicians per 100,000 people
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Akdağ R (Ed.) HEALTH TRANSFORMATION PROGRAM IN TURKEY PROGRESS REPORT 2010 Republic
of Turkey,
Ministry of Health Publication No: 807
Comparison of EU Average, WHO European Region Average and
Turkey for the Number of Practitioners per 100,000 people
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The number of Physicians per 100,000 People in European Countries
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and Turkey
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López-Cevallos DF, Chi C. Assessing the context of health care utilization in Ecuador: A spatial and
multilevel analysis. BMC Health Services Research 2010;10:64
Summary
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