Medical Education Blog

My task is to use a case to illustrate how diversity impacts the work of a medical professional. I have chosen to discuss a philosophy known as “patient centered medicine” to illustrate this topic. I have framed the components of this clinical method into 3 sections and each will be briefly discussed in terms of a patient case.

Method
• Interview in a patient centered fashion
• Understand the patient as a whole person
• Diagnosis and treatment plan – “find common ground”

Case
• 56 y first nations woman
• Thirsty, losing weight, fatigued, frequent urination, always feels hungry
• Family history of “sugar” diabetes – recent death of mother age 78Y MI, kidney failure; 1 older sister had leg amputated
• Smoker, lives on reserve, married, 2 adult dependent children
• Obese, bp 148/88, hr 100, mm dry, white patches in buccal mucosa
• Random chemstrip 10.1 mmol/l

Patient Centered Medicine

• Effective patient care requires attention to the patient’s personal experience of ill health (ILLNESS).
• To identify the medical abnormality or problem (DISEASE) is the goal of the physician.
• Using a patient-centered approach can help integrate both the patient’s and the physician’s agenda.
• The four aspects of the approach are:
1. their feelings, especially fears about being ill;
2. their ideas about what is wrong with them;
3. the impact of their problems on their functioning; and
4. their expectations about what should be done.

CASE ILLUSTRATION

• while the medical information in this scenario may seem straightforward to obtain
(eg. have you been more tired than usual? Yes. Have you been urinating more frequently than usual? Yes.) it is important to really listen to the patient about her illness experience and how it is impacting her life; by doing so, you show respect for her as an individual with unique beliefs which may be very different from your own…
• in the context of this case, as a medical professional you are obligated to discuss her use of tobacco smoke and how it increases her risks of co-morbid health problems; HOWEVER, it is important to explore her reasons for smoking (the stress of loss of her mother and her sister’s ill health) and respect the fact that certain types of ceremonial grasses are smudged for health and spiritual reasons among difference aboriginal groups.

HOW DOES THIS METHOD BRING ISSUES ABOUT DIVERSITY INTO THE INTERVIEWING PROCESS?

• By using the feelings, ideas, fears and expectations guideline, it allows the person to exist outside of your diagnostic questions
• Eg. the patient may have deep-seated fears against the use of insulin because her sister’s leg amputation was preceded by a leg infection caused by the infection of an insulin injection site on her leg. If you are not aware of this fact, your attempts at a treatment plan may be met with resistance or quietly disregarded to both parties detriment.

Understanding the whole person

• information accumulated about the patient that helps the clinician understand both the DISEASE and the ILLNESS experience for this patient
• it includes family, work, recreation, religious OR spiritual beliefs, and/or various life crises
• reviewing the “Current Life Situation” or Social history of a patient will help reveal cultural beliefs and attitudes that may have an impact on patient care

CASE ILLUSTRATION
• you may want to explore her support network and the resources available to her that can help her cope with this new diagnosis
• in this case, our patient’s mother just passed away; this woman now has become the primary care giver for her sister; this is the same sister with a leg amputation secondary to complications brought on by diabetes; her family members had sought out a traditional aboriginal healer to assist with the diabetes; this patient is torn between her traditional beliefs in medicine and her desire to get some opinions from a “regular doctor”

HOW DOES THIS METHOD BRING ISSUES ABOUT DIVERSITY INTO THE INTERVIEWING PROCESS?

• Again, by exploring the patient’s life situation, you may receive information about her that becomes very valuable in the formation of the treatment plan
• A question to use might be, “What treatments have you tried to alleviate your current symptoms? Please feel free to tell me about any herbal or alternative treatments you have tried.”

Finding Common Ground

• The physician’s plan is only as good as the patient thinks it is
• The patient and clinician need to reach some form of agreement in 3 areas:
1. the nature of the problem (DISEASE) and priorities
2. the goal of treatment
3. the roles of the patient and the doctor

CASE ILLUSTRATION

• the clinician in this case knows what the disease is, i.e. Type 2 Diabetes and has a very specific agenda: labwork, physical examination, medication recommendations, lifestyle counseling, and follow up are just the beginning of all the doctor’s “orders”
• it is important that the clinician involved respects what this woman can and cannot do at this point and individualizes therapy options with her
• Eg. The patient is very willing to get her labwork done and understands she most likely has diabetes; however, she feels she cannot quit smoking at this point. She agrees to your medication suggestions and confides she just “wants to feel better”. She is relieved that you do not suggest insulin at this point.

HOW DOES THIS METHOD BRING ISSUES ABOUT DIVERSITY INTO THE INTERVIEWING PROCESS?
• At this point in the case, you know a great deal about the patient; it is now up to you to use it.
• For example, this patient may not be able to attend the regularly scheduled diabetes education classes in the city because she is from a rural reserve; transportation into the city is not always easy, especially in the winter months; part of the treatment plan may include you preparing a package of information about diet and blood sugar monitoring for a new diabetic; she could make some inquiries at the on-reserve health center about local diabetic resources and classes.

Summary

It is obvious that diversity plays a large role in day-to-day interaction with patients. To explore beyond the more obvious immediate complaints of the patient will hopefully lead to a better understanding of the current problem. With this understanding, you can hope to provide a more comfortable atmosphere for the patient, one which leads to better compliance and better outcomes for both the patient and the clinician.