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Procrustes and Primary Care. Dee Mangin. Effective Care. Recognition of the patients needs Consideration by professional and patient of the best that medical science has to offer Context a relationship that will maximise the therapeutic effect of using or not using treatments.

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Procrustes and Primary Care


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effective care
Effective Care

Recognition of the patients needs

Consideration by professional and patient of the best that medical science has to offer

Context a relationship that will maximise the therapeutic effect of using or not using treatments

slide7

Dr. Cabot employed new diagnostic techniques in his practice with patients, techniques that were sometimes ignored by his patients

slide12
Evidence based medicine

risks becoming

Scientific - bureaucratic medicine

the consultation
The Consultation

“The occasion when in the intimacy of the consulting room or sick room, a person seeks the advice of a doctor, whom she trusts. This is a consultation and all else in the practice of medicine derives from it.”

Sir James Spence

real populations
Real populations

In primary care 40% of new presentations never fit criteria for any known diagnosis

In primary care 40% of patients have multiple comorbid conditions

slide19

Infectious diseases

Heart disease

Proportion of total deaths

Cancer

slide20

“hypertensive DISEASES, ischemic heartDISEASES, rheumatic fever, pulmonary heart DISEASE and DISEASES of the pulmonary circulation, other forms of heart DISEASE cerebrovascular DISEASES or stroke, DISEASES of veins, lymphaticvessels, and lymph nodes, OTHER AND UNSPECIFIED DISORDERS OF THE CIRCULATORY

SYSTEM, AND congenital MALFORMATIONS, or birth

defects of the circulatory system.”

slide24

drew blood from his body

forced him to vomit violently

gave him a strong laxative

shaved his head

applied blistering agents to his scalp

put special plasters made from pigeon droppings onto the sole of his feet

fed him gallstones from the bladder of a goat

made him drink 40 drops of extract from a dead man's skull

slide25
Hypothetical >70 year old woman

COPD

Type 2 diabetes

Hypertension

Osteoarthritis

Osteoporosis

slide26
19 doses of 12 different medications

Taken at five times during the day

14 non pharmacological activities

10 different possibilities for significant medicine interactions either with other medicines or other diseases

slide27

Men occasionally stumble over the truth, but most of them pick themselves up and hurry off as if nothing ever happened

slide32

Clinical state and circumstances

Research

evidence

Patients’

preferences

and actions

Improved health outcomes

patient priorities
Patient priorities

“Life itself is not the most important thing in life. Some cling to it as a miser to his money and to as little purpose. Some risk it for a song, a hope, a cause, for wind in their hair.”

Sir Theodore Fox

slide34
Professionals relying on epidemiological knowledge to guide their enquiries about unmet needs in older patients may find that the needs that they identify are not perceived as unmet, or even meetable, by their patients

Drennan V et al Fam. Pract. 24:454-460, 2007

slide36

What characterizes illness is its

variability, not its average

manifestations. Virtually all of the

conclusions of randomized controlled

clinical trials are based on the average

response. Variability, which underlies

the genesis and progression of illness,

the role of risk factors, and the impact

of interventions, goes unrecognized.

the art of not doing well
The Art of Not Doing, Well

“It is an art of no little importance to administer medicines properly: but, it is an art of much greater and more difficult acquisition to know when to suspend or altogether to omit them.”

Philippe Pinel Treatise on Insanity

discriminatory prescribing
Discriminatory Prescribing

“It is an art of no little importance to administer medicines properly: but, it is an art of much greater and more difficult acquisition to know when to suspend or altogether to omit them.”

Philippe Pinel Treatise on Insanity

discontinuation
Discontinuation

BP lowering

35 - 40% remained normotensive

Bain K et al. JAGS. 2008; 56: 1946-52

199 ‘disabled’ patients in residential care

Stopped 332 medicines (mean 2.8 / patient)

Garfinkel D Israel Medical Association Journal 2007: 9:430-4

slide48

311 medications in 64 patients (58%) of drugs discontinued

  • 4/5 didn’t have to be restarted
  • 80% reported a global improvement in health
  • No adverse events from the discontinuations
effective care1
Effective Care

Recognition of the patients needs

Consideration by professional and patient of the best that medical science has to offer

Context a relationship that will maximise the therapeutic effect of using or not using treatments

slide50

The evidence is strong that no matter how technically correct a medical transaction might be, patients do not get better at the same rate, if they did not feel that their needs were heard and understood over the course of their medical encounters.18, 160-167

effective care2
Effective Care

Recognition of the patients needs

Consideration by professional and patient of the best that medical science has to offer

Context a relationship that will maximise the therapeutic effect of using or not using treatments

better primary care gives better health outcomes
Better primary care gives better health outcomes

Source: Starfield B. www.pitt.edu/~super1/lecture/lec8841/index.htm

fit for purpose
Fit for Purpose
  • Primary care that meets primary care standards
  • Secondary care that meets secondary care standards
critical structural features
Critical Structural Features
  • Accessibility
  • Mechanisms of continuity of care
  • Range of services available in primary care

.

the evidence based primary care functions that achieve this are
The evidence-based primary care functions that achieve this are
  • First contact for new needs/problems
  • Person (not disease) focused care (recognition of people’s health problems)
  • The range of services provided in primary care
  • Coordination (of treatment and needs recognition over time)