Patient-centred care

PATIENT-CENTRED CARE: A HYPOTHETICAL

XYZ Hospital (XYZH) treats many patients suffering the consequences of poorly-controlled type 2 diabetes mellitus (T2DM). Whilst I have come across a variety of interesting cases during placement, one case of a new patient stood out as an opportunity to create a patient-centred treatment plan.

The patient (Filbert) is a 54 year-old construction worker. He has a 25-year history of T2DM for which he took insulin for 10 years post-diagnosis. Filbert discontinued insulin and has not seen a general practitioner (GP) for 15 years as he “has not been sick”. Filbert believes his healthy weight means his diabetes is under control, but cannot remember the last time he checked his blood glucose level (BGL). Filbert stated he has no other medical conditions and takes no medications.

Filbert was first admitted to BHH in March 2014 for an ulcer on the dorsum of his right hallux. The ulcer began when Filbert scraped his hallux on a cabinet while attempting to kick his cat. Discussions with Filbert indicate he is independent, living alone, with the male attitude of ‘if it is not killing you, move on’.  Therefore, he ignored the wound until it became infected, then presented to ED and was admitted.

Filbert was put on IV antibiotics and nurses in the general medicine ward dressed the ulcer. BHH podiatry was not contacted. The ulcer showed signs of healing and Filbert was discharged after 3 days with instructions to take time off work until the ulcer fully-healed, not to place pressure on the ulcer, and to keep dressings dry. Filbert was to go to his GP three days later for a dressing change. Filbert went back to work the next day in steel-capped boots, resulting in further deterioration of the ulcer. He stated he knew something was wrong, but he ignored the pain. Further, he did not go to his GP for a dressing change, instead making makeshift dressings at home.

In April his ulcer became infected again and he presented to ED, once again being admitted for IV antibiotics. Filbert’s HbA1c was measured at 13.5%, and his blood pressure was 160/103. I undertook a diabetes assessment; results are as follows: 

Assessments	Results
	Left	Right
Neurological
10g monofilament Graduated tuning fork	10/10	9/10
	5/5	5/5
Vascular
Hair growth Nail growth Skin status Pulses (dosalis pedis, posterior tibial) Doppler ABI Toe pressures	Present	Present
	Present, healthy	Present, healthy
	Intact	Intact
	Palpable and strong	Palpable and strong
	Triphasic	Triphasic
	1.16	1.2
	Not indicated	Not indicated
Dermatological	Nothing to note	Nothing to note
Biomechanical
Deformities ROM: Ankle Subtalar Midtarsal 1st MTPJ	None	None
	Very restricted (0° dorsiflexion)	Very restricted (0° dorsiflexion)
	Restricted	Restricted
	Restricted (both axes)	Restricted (both axes)
	Very restricted (10° dorsiflexion)	Very restricted (10° dorsiflexion)

During the assessment, Filbert was agitated at being in a room with patients he continuously described as being “weak” and “annoying”.

An MRI found osteomyelitis present. Vascular surgeons determined the hallux had to be amputated, but general medicine insisted on long-term antibiotics and Filbert was discharged. He was to return to BHH podiatry after my placement ended for weekly dressing changes. I presented my findings to my supervisors and suggested ways to incorporate patient-centred care (PCC).

PCC involves shared decision-making that incorporates patient preferences, emotional needs, culture, values and health perspectives, while understanding that the patient is a partner in achieving optimal health (Legare et al., 2010; Stanbrook et al., 2012; Griffin et al., 2014; Stewart, 2001). The practitioner must exhibit an understanding and respect for patient factors to better relate to the patient and achieve the patient’s goals while incorporating necessary elements of health promotion and integrated care (Stewart, 2001).

The Podiatry Board of Australia (2014) states PCC is a priority in the provision of care, and for good reason. PCC leads to feelings of empowerment and hence improved compliance and satisfaction as well as the feeling that the patient’s emotional issues have been addressed (Griffen et al., 2004; Dwamena et al., 2012). A systematic review by Griffen et al. (2004) found that improvement in principal health outcomes was favoured in 74% of the included trials that incorporated PCC, significantly in 40%.

Some practitioners believe PCC is time-intensive and expensive, finding it more efficient and in the patient’s best interest to dictate care (Dunn, 2003; West, Barron, and Reeves, 2004). Platt et al. (2001) found the opposite true, depending on how questions are phrased. Open-ended questions and the use of phrases such as “anything else?” may elicit all relevant health information, providing a holistic picture of the patient including their experience of illness. A complete picture of a patient results in less backtracking or altered findings (Epstein & Street, 2011).

Open-ended questions are also associated with increased trust, belief in practitioner competence, and comfort disclosing information, including potential barriers to health (Baker, O’Connell, and Platt, 2005; Fiscella et al., 2004).  Epstein et al. (2005) found this open dialogue and trust results in significant cost savings. Patients who trust their practitioners are less likely to ask for more tests to explore all options. Further, practitioners, having a fuller understanding of the patient, order more specific tests and prescribe tailored treatments, resulting in reduced length of hospitalisations.  

Finally, patient discussion welcomes the involvement of multidisciplinary teams, spreading the workload while providing more appropriate care (Bauman, Fardy, and Harris, 2003). Multidisciplinary teams have been shown to improve self-management and care, both critical for T2DM (van Dam, van der Horst, van den Borne, Ryckman, and Crebolder, 2002).

Whilst PCC has been shown to be beneficial, there are barriers to its incorporation. PCC is often incorrectly implemented because a universal definition of PCC does not exist (Gillespie, Florin, and Gillam, 2004; West, Barron, and Reeves, 2004). Some believe PCC involves informing patients and gaining their trust while the health professional remains the decision-maker, re-badging the status quo. Others believe it means acquiescing to patient requests, potentially why some studies conclude that PCC does not improve patient outcomes (Gillespie, Florin, and Gillam, 2004). Also, practitioners may be resistant to change due to the belief that it is time-intensive (West, Barron, and Reeves, 2004).

Other barriers include social disadvantage, language and cultural differences (Gillepsie, Florin, and Gillam, 2004; Epstein & Street, 2011). It is difficult to create a shared understanding of health and subsequent health decisions if there is a lack of understanding between the stakeholders, whether due to linguistic, cultural, or social barriers. If the patient lacks confidence due to these factors or low health literacy, he or she will be less confident in asking questions and feel as if he or she has nothing important to contribute (Epstein & Street, 2011).

Filbert’s case is an example of poor PCC. First, general medicine did not consult vascular or podiatry until his second admission. This was a neglected opportunity demonstrated by the fact that Filbert was interested in how podiatry could help ensure wound healing and non-recurrence. This interest was not fostered, and Filbert had no knowledge of the podiatric consequences of diabetes. Podiatric participation may have changed the present outcome; but its future incorporation will help ensure it does not reoccur. Other disciplines should have been involved, and their care more coordinated. Conflicting information throughout his admissions furthered Filbert’s distrust of the medical profession, a barrier to future PCC.

Further referrals are hereafter required to demonstrate to Filbert that a holistic approach is being taken. Whilst Filbert’s elevated blood pressure could have been due to stress from being in a hospital, his GP should be notified and if necessary, pharmacologic and lifestyle therapy should be undertaken (American Diabetes Association, 2010).

Filbert’s HbA1c and lack of BGL monitoring indicate he needs intervention from endocrinology and a diabetes educator, two of my recommendations to podiatry. An endocrinologist can monitor his BGLs and incorporate medication-based interventions for control. Further, Filbert equates healthy weight with BGL control. Whilst Filbert’s job keeps him active, his diet of steak, chips, and beer is less than ideal. A diabetes educator will assist Filbert in being active outside of work, eating well, monitoring his BGLs, and reducing diabetes risks (Mulcahy et al., 2003). Education needs to be provided with the aim of modifying Filbert’s perceptions and attitude towards diabetes (Puder 2003).

Filbert needs to be engaged in decision-making processes, forming an alliance with the multidisciplinary team. It is imperative that the team creates a partnership with Filbert and does not substitute their goals for Filbert’s (Mulcahy et al., 2003). The team needs to begin by gaining an awareness and acceptance of what motivates action and intervention from Filbert (Epstein & Street, 2011). This was a missed opportunity by general medicine and vascular, who should have determined what is important to Filbert, as well as his abilities and concerns. For example, would Filbert be able to remember to take antibiotics? Would he be able to cope with a significant amputation if his osteomyelitis flared up? What were his concerns? Answers to these questions would have led to informed and shared decision-making (Epstein & Street, 2011). Further, trust would have been established, shown to lead to improved continuity of care and increased commitment to treatment plans, something Filbert has an issue with (Street, Makoul, Arora, and Epstein, 2008).

Whilst patient engagement is ideal, research has shown that people who are older, male, and less educated tend to request less information from practitioners and are less likely to get actively involved in their healthcare (Swenson et al., 2004; Krupat, Bell, Kravitz, Thom, and Azari, 2001; Addis & Mahalik, 2004; Galdas, Cheater, and Marshall, 2005). Filbert’s health literacy is low, demonstrated by his beliefs about diabetes control. This resulted in 15 years of nonexistent health care and an apparent disinterest and denial of his health status indicated by his statement that he was different from the other patients. Therefore, while appropriate referrals may be made, will Filbert be able to shed his masculine views and partake in multidisciplinary care?

Filbert is independent and consultations with other disciplines may be meaningless unless he is able to change the way he views diabetes. In the time spent with Filbert, I gained a good sense of his beliefs about his health and concerns. The largest obstacle is Filbert’s belief he is healthy and thus does not require medical treatment. To increase the chance that Filbert seeks help from a multidisciplinary team and views T2DM as an important issue, a psychologist needs to be involved to address how Filbert’s views impact his health and help-seeking behaviours (Mahalik, Englar-Carlson, and Good, 2003). Also, people such as Filbert have been shown to be better at problem-solving and assertiveness, two aspects a psychologist could be able to foster (Mahalik, Englar-Carlson, and Good, 2003).

Normally, a psychologist would be one of the group of health professionals Filbert would not seek help from, but during my assessment he showed concern about what was going to happen to him from this point on. This would be the perfect time to incorporate psychology into his care. Filbert needs the opportunity to reflect on his current circumstances, why he was there, and how he and the team can ensure that this will not reoccur. The psychologist should coordinate with the diabetes educator to examine Filbert’s motivations for change (outside of health), and attempt to overcome barriers to implementation of recommendations from the diabetes educator (Mulcahy et al., 2003).

Filbert presented an interesting case of how PCC can be incorporated to achieve better outcomes. While Filbert’s case is complex, the incorporation of a multidisciplinary team with an understanding of what motivates and concerns him may change his attitude towards the need for health and self-care (Donohoe et al., 2000).

References

 

Addis, M.E., & Mahalik, J.R. (2004). Men, masculinity and the contexts of seeking help. American Psychologist, 58(1), 5 – 14.

American Diabetes Association. (2010). Executive summary: Standards of medical care in diabetes – 2010. Diabetes Care, 33(Supp. 1), S4 – S10.

Baker, L.H., O’Connell, D., & Platt, F.W. (2005). “What else?” Setting the agenda for the clinical interview. Annals of Internal Medicine, 143(10), 766 – 770.

Bauman, A.E., Fardy, H.J., & Harris, P.G. (2003). Getting it right: Why bother with patient-centred care? The Medical Journal of Australia, 179(5), 253 – 256.

Dunn, N. (2003). Practical issues around putting the patient at the centre of care. Journal of the Royal Society of Medicine, 96, 325 – 327.

Dwamena, F., Holmes-Rovner, M., Gaulden, C.M., Jorgenson, S., Sadigh, G. Sikorskii, A., …Beasley, M. (2012). Interventions for providers to promote a patient-centred approach in clinical consultations. Cochrane Database of Systematic Reviews 2012, Issue 12. Art. No.: CD003267. DOI: 10.1002/14651858.CD003267.pub2.

Epstein, R.M., & Street, R.L. (2011). The values and value of patient-centred care. Annals of Family Medicine, 9(2), 100 – 103.

Fiscella, K., Meldrum, S., Franks, P., Shields, C.G., Duberstein, P., McDaniel, S.H., & Epstein, R.M. (2004). Patient trust: Is it related to patient-centred behavior of primary care physicians? Medical Care, 42(11), 1049 – 1055.

Galdas, P.M., Cheater, F., & Marshall, P. (2005). Men and health help-seeking behaviour: Literature review. Journal of Advanced Nursing, 49(6), 616 – 623.

Legare, F., Ratte, S., Stacey, D., Kryworuchko, J., Gravel, K., Graham, I.D., & Turcotte, S. (2010). Interventions for improving the adoption of shared decision making by healthcare professionals. ochrane Database of Systematic Reviews 2010, Issue 5. Art. No.: CD006732. DOI: 10.1002/14651858.CD006732.pub2.

Gillespie, R., Florin, D., & GIllam, S. (2004). How is patient-centred care understood by clinical, managerial and lay stakeholders responsible for promoting this agenda? Health Expectations, 7, 142 – 148.

Griffin, S.J., Kinmonth, A.L., Veltman, M.W.M., Gillard, S., Grant, J., Stewart, M. (2014). Interventions to alter the interaction between patients and practitioners: A systematic review of trials. Annals of Family Medicine, 2(6), 595 – 608.

Krupat, E., Bell, R.A., Kravitz, R.L., Thom, D., & Azari, R. (2001). When physicians and patients think alike: Patient-centred beliefs and their impact on satisfaction and trust. Journal of Family Practitioners, 50, 1057 – 1062.

Mahalik, J.R., Englar-Carlson, M., & Good, G.E. (2003). Masculinity scripts, presenting concerns, and help seeking: Implications for practice and training. Professional Psychology: Research and Practice, 34(2), 123 – 131.

Mulcahy, K., Marynluk, M., Peeples, M., Peyrot, M., Tomky, D., Weaver, T., Tarborough, P. (2003). Diabetes self-management education core outcomes measures. The Diabetes Educator, 29(5), 771 – 803.

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Stewart, M. (2001). Towards a global definition of patient centred care. BMJ, 322, 444 – 445.

Street, R.J., Makoul, G., Arora, N.K., & Epstein, R.M. (2008). How does communication heal? Pathways linking clinican-patient communication to health outcomes. Patient Education and Counseling, 74(3), 295 – 301.

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van Dam, H.A., van der Horst, F., van den Borne, B., Ryckman, R., & Crebolder, H. (2002). Provider-patient interaction in diabetes care: Effects on patient self-care and outcomes. A systematic review. Patient Education and Counseling, 51(1), 17 – 28.

West, E., Barron, D.N., & Reeves, R. (2004). Overcoming the barriers to patient-centred care; time, tools, and training. Issues in Clinical Nursing, 14, 435 – 443.

Langmore Podiatry in Berwick practices the patient-centred care approach to achieve the best outcomes for patients.