Transcript biomedically and contextually complicated (9%)

Contextual Care
Class 2, 12.09.2012
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
– Discuss consequences of contextual errors in medicine
– Discuss health literacy and its relationship with
contextual care
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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 because 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 alcoholism
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• Physical exam normal
• Liver transaminases are slightly increased
• Doctor asks to discontinue alcohol for 2
weeks
• 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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Proximal Context
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Family
Finances
Education
Employment
Leisure
Social support
These issues are looked at, not as isolated facts, but in terms
of how they affect the patient with the illness
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Distal Context
• Community – extended family, resources
needed
• Culture
• Economics
• Healthcare system
• Sociohistorical issues
• Geography
• Ecosystem
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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 (elements of a patient’s environment or
behavior that are relevant to their care, including
their economic situation, access to care, social
support, and skills and abilities). In contrast to
biomedical errors, which are not patient-specific,
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
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Individualizing Patient Care: A Multicenter Study. Annals of Internal Medicine 2010;153(2):69-77
• Physicians probed fewer contextual than
biomedical hints.
• They provided error-free care more often
in the uncomplicated encounters (73%) than
in the biomedically complicated (38%),
contextually complicated (22%), or
biomedically and contextually complicated
(9%) 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!
• “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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Health Literacy
http://www.annfammed.org/cgi/reprint/3/6/514
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Scoring of “The newest vital sign”
1. If you eat the entire container, how many calories will you eat?
2. If you are allowed to eat 60 g of carbohydrates as a snack, how much
ice cream could you have?
3. Your doctor advises you to reduce the amount of saturated fat in your
diet. You usually have 42 g of saturated fat each day, which includes
1 serving of ice cream. If you stop eating ice cream, how many grams
of saturated fat would you be consuming each day?
4. If you usually eat 2500 calories in a day, what percentage of your
daily value of calories will you be eating if you eat one serving?
5. Pretend that you are allergic to the following substances: Penicillin,
peanuts, latex gloves, and bee stings. Is it safe to eat this ice cream?
6. Why or why not?
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Also the availability of health resources
are not same in all regions
• The number of health personnel is less in
rural areas and small cities compared with
urban and large cities.
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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
Summary
• Explain the importance of contextual care in
family practice
• What is the approximate percentage of
giving correct health service in case of a
contextual error?
• What is the importance of health literacy in
giving health services?
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