Class 2, 12.09.2011 Atatürk University Medical Faculty

1. ContextualCare Class 2, 12.09.2011 Atatürk University Medical Faculty Zekeriya Aktürk, Prof. zekeriya.akturk@gmail.com http://aile.atauni.edu.tr / 25

2. 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 • Mention methods in evaluating family functioning • Discuss the effect of family atmosphere in health care provision / 25

3. One Case • 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 / 25

4. Work schedule very hectic • Couldn’t work 3 days beause 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 alcoholoism / 25

5. Physical exam normal • Doctor asks to discontinue alcohol for 2 weeks ad do a barium x-ray • Liver transaminases slightly increased • Jackie returns to doctors office to discuss the tests • Her abdominal pain is markedly improved / 25

6. 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 / 25

7. 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 / 25

8. 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 / 25

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10. How to assess family function? • Family circle • Family Apgar • FACES http://www.facesiv.com/ / 25 http://etd.lib.ttu.edu/theses/available/etd-11252008-31295011191763/unrestricted/31295011191763.pdf

11. 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. 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 Individualizing Patient Care: A Multicenter Study. Annals of Internal Medicine 2010;153(2):69-77 / 25

12. Physicians probed fewer contextual than biomedical hints. • They provided error-free care more often in the uncomplicated encounters (73%) than in the biomedically (38%), contextually (22%), or biomedically and contextually (9%) complicated encounters. / 25

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15. 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 fiber! / 25

16. Smith PH, Murray CE, Coker AL. The Coping Window: A Contextual Understanding of the Methods Women Use to Cope With Battering. Violence and Victims, Volume 25, Number 1, 2010. / 25

17. “Well, yes, you are taking the pills, Arden. But howare you taking the pills?” • “I take the blue pill on one day, the white one thenext, 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.” / 25

18. In the solemn privacy ofthe examination room, I have asked my patients all mannerof intimate questions—about their sexual orientation; illicitdrug use; income and the affordability of medications;marital infidelity; the possibility of felonious behavior, as itmight have related to guilt and depression; or of wifebeatingand the abuse of children— but I have never in myrecollection asked a patient whether he could read or write. • Yet 1% of Americans are illiterate, and 30% to 40% areestimated to have inadequate or marginal health literacy / 25 LaCombe MA

19. It is estimated that 50% of Americans read so poorlythat they cannot properly read prescription drug labels and3 of 4 people on welfare cannot read at all LaCombe MA. Contextual Errors. Annals of Internal Medicine 2010;153(2):126-127 / 25

20. Also the availability of health resources are not same in all regions • Küçük şehirlerde, doğu ve güneydoğuda ve kırsal alanda sağlık personeli sayısı ve niteliği diğer bölgelere göre daha azdır. / 25

21. Comparison of EU Average, WHO European Region Average and Turkey for the Number ofPhysicians per 100,000 people / 25 Akdağ R (Ed.) HEALTH TRANSFORMATION PROGRAM IN TURKEY PROGRESS REPORT 2010 Republic of Turkey, Ministry of Health Publication No: 807

22. Comparison of EU Average, WHO European Region Average and Turkey for the Number ofPractitioners per 100,000 people / 25

23. The number of Physicians per 100,000 People in European Countries and Turkey / 25

24. / 25 López-Cevallos DF, Chi C. Assessing the context of health care utilization in Ecuador: A spatial and multilevel analysis. BMC Health Services Research 2010;10:64

25. Summary / 25