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PATIENT CENTRED CLINICAL
METHOD
M.O. Ogunsanya
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Outline
Overview
Doctor(Dx Oriented) Clinical Methods(DCCM)
Patient Centred Clinical Methods Patient Centred Care
Elements of PCCM
Components of PCCM Patient Centred Consultation
Case Study
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Health professionals do not deal with disease;
they deal with people who are concerned
about their health.
Patient Centred Clinical Method (PCCM) is a
clinical method designed to elicit an
understanding of the patient andhis disease.
PCCM looks at 2 agendas namely, the
Physiciansand the Patients.
Overview
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PATIENT PRESENTS
CUES OF UNWELLNESS
DOCTOR SEARCHESTWO PARALLEL AGENDAS
DOCTORS AGENDA PATIENTS AGENDA
- Hx- PE
- Lab Investigation UNDERSTANDING
ILLNESS EXPERIENCE
DIFFERENTIALDIAGNOSIS
INTEGRATION
The Patience-centered Clinical Method
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Doctor(Disease Oriented) Centred
Clinical Method (DCCM)
Method used by most practitioners and taught
in medical school.
In doctor centred consultations, their medical
skills and knowledge predominate.
They maintain control by using closed
questions and giving the patient directions.
The patients perceptions and preferences are
not explored.
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Patient Centred Clinical Methods
(PCCM)
Focus began in the 1970s when
The two terms DCCM and PCCM were coined
PCCM practiced partially in private settingsthough practitioners unaware of this
Platform for ensuring Patient Centred Care
What then is Patient Centred Care?
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Patient Centered Care
Being patient centered means health care
providers take into account the patients
desire for information and for sharing
decision making.
Patient centered care requires a thorough
explanation of disease to patients and
exploration of their feelings, beliefs andexpectations.
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Patient Centered Care
It is the interaction between the clinician and
the patient, and the clinicians ability to use
the patients knowledge and experiences to
guide the consultation.
Patient centred interviews recognize patients
needs and preferences by encouraging them
to voice ideas and collaborate in theconsultation.
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Patient Centred Care
Patient centred care is not:
- technology centred
- doctor centred- hospital centred
- disease centred
Rather these components revolve around thepatient.
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Why Patient Centred Care?
Enhances patient satisfaction
Improves patient outcomes
Has a positive impact on health care utilizationcosts
Is associated with positive benefits for health
professionals such as greater job satisfaction
Is associated with fewer malpractice claims
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Fundamental Elements of PCC
Elements fundamental to patient centred care
are:
- Respect for the individuals values,
expressed needs and preferences.
- Choicepatients have the right and
responsibility to participate in health care
decisions including treatment and
management.
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Fundamental Elements of
PCC(cont)
- Access to services required by the persons
medical condition, including preventive care.
- Supportacknowledging and addressing the
persons emotional and social needs. This
means involving the persons family and
friends (as the patient desires) and
considering educational, cultural and personalfactors affecting the persons ability to
manage their condition.
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Fundamental Elements of
PCC(cont)
- Education and information that is accurate,
relevant and answers the persons concerns.
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PCCM - Clinical Consultation in PCC
Clinicians skills to customize care to the
specific needs and circumstances of each
individual, that is, to modify care to respond
to the person, not the person to the care.
Clinicians to think about ways of integrating
patients perceptions into consultations
Focus is on the partnership between patients,
families and providers with acknowledgement
of patients treatment and life goals.
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Components of PCCM
Exploring both the disease and illness
experience
Understanding the whole person
Finding common ground regarding
management
Incorporating prevention and health
promotion
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Components of PCCM
Enhancing the doctor-patient relationship
Being realistic about personal limitations and
issues such as the availability of time and
resources
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The Patient-Centred Clinical Method
Six Interactive Components
1. Exploring both the disease and the illness experience:
o history, physical, lab;
o dimensions of illness (feelings, ideas, effects on function and
expectations).
2. Understanding the whole person:
o the person (e.g. life history, personal and developmental issues);
o the proximal context (e.g. family, employment, social support); and
o the distal context (e.g. culture, community, ecosystem).
3. Finding common ground:o problems and priorities;
o goals of treatment and/or management; and
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4. Incorporating prevention and health promotion:
o health enhancement;
o risk avoidance;
o risk reduction;
o early identification; and
o complication reduction.
5. Enhancing the patient-health care practitioner relationship:o compassion;
o power;
o healing; and
o self-awareness.
6. Being realistic:o teambuilding and teamwork
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Patient Centred Consultation
Explore the patients main reason for the visit,
concerns, and need for information.
Explore patients social supports and physical
environment, which may influence their
health (e.g. family attitudes to healthy
behaviour change)
Find common ground on what the problem is
and mutually agree on management.
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Patient Centred Consultation
Find out whether and to what extent the
person wants to participate in decision-
making. This might be influenced by age,
culture and education.
Find common ground for planning ongoing
management so that the health professional
and the patient can agree on what should bedone.
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Patient Centred Consultation
Negotiate an agreed individualized written
disease management plan, including specific
strategies for dealing with acute symptomatic
episodes.
Emphasize prevention and health promotion
Ensure the continuing relationship between
the patient and the doctor
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Questions to answer during Patient
Centred Consultation
Who is the patient? What does this patient
want from the doctor - Today and in the long
run?
How does this patient experience this illness?
What are the patients ideas about the illness?
What are the patients main feelings about the
illness, with attention to five common
responses: fear, distrust, anger, sadness, and
ambivalence?
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Clinical Methods
Doctors can refine their skills in ways that
allow them to better attend to the person of
the patient.
Patient activation is an important component
of patient centred interviewing.
It enables the patient to take control within
the consultation and promotes self
management.
- Often a request, tell me about yourself will
suffice.
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A 68-year-old male patient, who hadrecently been operated on for a benignstricture of the sigmoid colon presented fora routine follow-up office visit.
The patient, a retired Roman Catholic
priest, had very recently taken up residencein a retirement home for ageing clergy.
All these facts were known to the doctor.The interaction has been reconstructed in
two ways to illustrate the disease- andpatient-centred methods.
CASE STUDY TO ILLUSTRATE DCCM & PCCM
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CASE STUDY TO ILLUSTRATE DCCM
The Disease-Centred Method
Doctor Hello Father Smith, how are you
today?
Patient Fineexcept for my headaches . . .
Doctor . . . and your operation, how's that
going?
Patient Fine.Doctor Bowels working?
Patient Yes.
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CASE STUDY TO ILLUSTRATE DCCM
Doctor Appetite?
Patient A bit poorly.
Doctor Have you lost any weight?
Patient No.
Doctor Well, obviously your loss of appetite
hasn't affected anything, so it can't be too
bad? Any nausea or vomiting?
Patient None.
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Doctor Any pain at the operation site?
Patient Not really.
Doctor Are you eating the bran we
recommended?
Patient No.
Doctor You must please stick to our
recommendations. We don't want any
recurrences.
Patient (sighing) Yes.
CASE STUDY TO ILLUSTRATE DCCM
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CASE STUDY TO ILLUSTRATE DCCM
Doctor Good, well the operation seems to
have been a success and there don't seem tobe any complications. Have you any other
complaints?
Patient I have this headache.
Doctor Is your vision affected?
Patient No.
Doctor Any weakness or paralysis of yourlimbs?
Patient No.
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CASE STUDY TO ILLUSTRATE DCCMDoctor Where are your headaches?
Patient At the back of my head.
Doctor Do they throb?
Patient Yes.Doctor How long do they last?
Patient About four hours
Doctor What takes them away?Patient I just lie down
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Doctor How often do they come?
Patient About twice a week.
Doctor How long have they been there for?
Patient Ever since I've been at the home.
Doctor Good, well you needn't worryit
can't have anything to do with your operation.
They are tension headaches. Perhaps we can
give you some paracetamol for it. The home
you have just moved into seems to havebeautiful gardens.
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CASE STUDY TO ILLUSTRATE DCCM
Patient Yes.Doctor It really is good of the church to care
for its elderly and it must be comforting to
have company.
Patient Yes.
Doctor Well good. Come and see me in a
month's time and we'll see how things aregoing. Take care.
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CASE STUDY TO ILLUSTRATE PCCM
The Patient-Centred Method
Doctor Hello Father Smith, how are youtoday?
Patient Fine, except for my headaches.
Doctor What about your headaches?
Patient Well, I've been getting them about
twice a week at the back of my head and they
bother me so I can't do anything, and I have to
lie down.
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CASE STUDY TO ILLUSTRATE DCCMDoctor You can't do anything? What's that
like for you?Patient It's frustrating, they're interfering
with the writing I want to get done and
nobody seems to understand . .Doctor Understand?
Patient All the other priests are so old and
decrepit in that place. All they can talk aboutis their aches and pains. I'm ashamed to say
they make me sick.
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CASE STUDY TO ILLUSTRATE DCCM
Doctor Why are you ashamed?
Patient Well, I shouldn't really talk that way
about them, they mean no harm . . . I feel so
guilty about it.
Doctor What do you mean guilty?
Patient I feel that my anger is unjustified, I'm
so frustrated that no one understands that I
wish to write.
Doctor It must be frustrating . . .
Patient Yes, it is and my headachesmy
headaches make it worse.
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CASE STUDY TO ILLUSTRATE DCCM
Doctor When did they first start?
Patient Ever since I've been at the home.
Doctor Why do you think that is?
Patient I . . . don't know, I haven't reallythought about it . . . do you think it's tension?
. . . I mean the people at the home . . . is it
possible?
Doctor What do you think?
Patient Well the whole situation at the
home does trouble me.
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CASE STUDY TO ILLUSTRATE DCCM
Doctor Would you like to talk about it more?
Patient No, not now, perhaps later.
Doctor Well, feel free to discuss it anytime
you like.
Patient Mmm, mmm, I will.
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CASE STUDY TO ILLUSTRATE DCCM
Doctor Well, how are things going after your
operation?
Patient It seems okay.
Doctor What do you mean, it seems okay?
Patient Well I don't seem to be eating well
and I can't stand that bran. In fact I have no
appetite for food.
Doctor What do you think that could be due
to?
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CASE STUDY TO ILLUSTRATE DCCM
Patient I wonder if it's due to the tension I'mfeeling?
Doctor Mmm, mmm.
Patient I will really think about what we'vesaid and come back to see you again.
Doctor Fine, anything else today?
Patient Fine, everything is fine, except I get afunny feeling on my scar.
Doctor A funny feeling?
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CASE STUDY TO ILLUSTRATE DCCM
Patient Yes, it seems a bit numb . . . I hope
it's not serious.
Doctor It's probably a little nerve that
supplies the skin that was cut during the
operation. Nothing to be concerned about.
Patient I'm glad it's only that. I was quite
worried.
Doctor Anything else you'd like to discuss?
Patient No, everything else is fine.
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CASE STUDY TO ILLUSTRATE DCCM
Doctor Good, would you like something for
your headaches?
Patient Thank you, but I don't think it's
necessary.
Doctor I'd like to see your wound in a
month's time, but we can get together earlier
if you'd like to.
Patient Fine, I'll be in touch, Doctor.
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Doctor centered (Disease centered) care
Seek after own expectation to establish a biomedical orclinical diagnosis.
Does not enter the patients world.
Misses subtle cues in the patientdoctor interaction.
Patient centered clinical care has
Patient guided interview
Expectations of the patient are discovered
Appropriate facilitative behaviour of the physician ineliciting patients feelings and fears
Any conflicts in both agenda are identified and dealtwith through Dr-Patient negotiation.
SUMMARY
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THANK YOU FOR LISTENING!
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Acknowledgements
Some Slides- courtesy Dr O.O. Imediegwu
(FMCGP)NPMCN Revision Course 2011
Patient Centred Care- Clinical Review
by Monica Bensberg www.dddgp.com.au ;
Accessed on 15/05/2012; 2:20pm
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References
Stewart M. Towards a global definition of
patient centred care. BMJ 2001; 322:444-5.
Brown, J. (2004). Patient-Centred
Collaborative Practice. Ottawa: Health
Canada.