Patient Centered Care Workshop:

1. Patient Centered CareWorkshop: Providing Quality Health Care to a Diverse Population Acknowledgement: This Workshop was Originally Developed by Faculty and Students at the Medical College of Wisconsin.

2. There is a nationally recognized need to address social and cultural diversity and disparities in health care LCME Standards AAMC Senior Graduation Questionnaire Data This workshop provides skills and process to Address Social and Cultural Diversity Address Ethnic and Socioeconomic Barriers/Disparities in Health Care. . . and Achieve excellence in patient care Patient Centered Care Rationale:

3. AAMC Sr. GQ 2006Population Medicine % “Inadequate Time”

4. AAMC Sr. GQ 2006Population Medicine % Inadequate

5. LCME Standard • ED-20. The curriculum must prepare students for their role in addressing the medical consequences of common societal problems…

6. LCME Standard • ED-21. The faculty & students must demonstrate an understanding of the manner in which people of diverse cultures and belief systems perceive health and illness and respond to various symptoms, diseases, and treatments.

7. LCME Standard • ED-22. Medical students must learn to recognize and appropriately address gender and cultural biases in themselves and others, and in the process of health care delivery.

8. Traditional MD Training:TheBiomedical Model Assumption • Health/Disease is explained by some measurable biological variable • Leaves little room for social, psychological, behavioral dimensions of illness • Patient's views re: healing/health care • Poverty • Racism, Sexism, Ageism, “…isms”

9. Patient Centered Care: The Three Perspective Approach • Patient: • Identify meaning of illness (Kleinman Questions) • Social Context ROS • Physician • Society Patient Centered Care Plan (that will Optimize Patient Outcomes)

10. Patient Centered Care:An Example • The patient is a 35-year old male with BP 176/100 • BP 2 months previous 170/100 • Biomedical Model - HTN • Per evidence-based guidelines, you Rx hydrochlorothiazide (HCTZ)

11. Where does it hurt When did it start? How long does it last? What makes it better or worse Write Rx per EBM protocol Understanding the DiseaseBiomedical Model “It”

12. Patient Centered Care: An Example

13. Biomedical Model of Care Where does it hurt When did it start? How long does it last? What makes it better or worse? Explanatory Model of Care/Meaning of Illness What are YOUmost concerned about How does it disrupt YOURlife? What do YOU think it is? How do YOU think I can help you? Understanding the Illness: The Patient’s Perspective Improved Health Care Outcomes

14. The Three Perspectives of Patient Centered Care: The Patient, The Physician, Society • PATIENT • PERSPECTIVE • Meaning of Illness • Social Context ROS • Impact on Patient • Impact on Others • Support Systems • Resources • Control of Environment • Literacy/Language Carrillo JE, Green AR, Betancourt JR. Cross-Cultural Primary Care: A Patient-Based Approach. Ann Intern Med 1999;130:829-834.

15. PATIENT PERSPECTIVE Meaning of Illness Social Context ROS PHYSICIAN PERSPECTIVES Biomedical model Biases EBM Values/Beliefs The Three Perspectives of Patient Centered Care: The Patient, The Physician, Society

16. PATIENT PERSPECTIVE Meaning of Illness Social Context ROS PHYSICIAN PERSPECTIVES Biomedical model Biases EBM Values/Beliefs The Three Perspectives of Patient Centered Care: The Patient, The Physician, Society PATIENT CENTERED CARE PLAN

17. PATIENT PERSPECTIVE PHYSICIAN PERSPECTIVE The Three Perspectives of Patient Centered Care:The Patient, The Physician, Society • SOCIETY • PERSPECTIVE • Poverty; Literacy; Culture • Underinsured • …ISM’s (racism, sexism)

18. PATIENT PERSPECTIVE PHYSICIAN PERSPECTIVE The Three Perspectives of Patient Centered Care:The Patient, The Physician, Society SOCIETY PERSPECTIVE Patient Centered Care Plan

19. Patient Centered Care: The Three Perspective Approach • Patient: • Identify meaning of illness to patient (Kleinman Questions) • Social Context (ROS) • Physician • Society • Be Realistic Patient Centered Care Plan (that will Optimize Patient Outcomes)

20. Objectives • Patient: • Apply the Kleinman questions to elicit each patient’s perspectives on health, disease, illness, and treatment • Apply the Social Context ROS

21. Objectives • Physician: Incorporate a patient centered approach in the daily care of patients • Society: Identify ethnic and socio-economic barriers and disparities in health care.

22. Patient Centered Care Today’s Agenda: • Background/Objectives • Critical Incident • “America in Black & White” - Nightline Video • “What I Have Learned About People and Poverty” • Frame: Patient Centered Care Plan • Eliciting Patient Values/Beliefs • Social Context ROS • Small Group Directions Small Group Discussion • Evaluation

23. Collaborative Working Group Members at MCW • Elizabeth Berdan, M3 • Douglas Bower, MD – Fam & Com Med • J. Sonya Haw, M2 • Gunnar Larson, MD – Psych & Beh Sci • Sajani Tipnis, MD - Pediatrics • Staci Young, MS – Fam & Com Med • Travis Webb, MD – Trauma Surgery • Sheri Galewski – Educ Services • Deborah Simpson, PhD – Educ Services

24. Critical Incident • Identify a recent patient for whom it was difficult to achieve excellence from your perspective as a physician. • Select patient who evoked a STRONG emotional reaction • Anger, frustration, annoyance, exasperation

25. Critical IncidentSelect a Patient • Patient should NOT be difficult due to their medical problem, but who was challenging for you because of the patient's • Expectations of you and/or health care system • Emotional state • Current social situation • Language, literacy • Beliefs/values • Other (e.g., ethnicity, race, country of origin, age)

26. Critical IncidentFor your selected patient • Briefly describe • The patient • Context/setting in which incident occurred • What evidence/incident/behavior evoked your reaction • Your approach/interaction with patient • Describe why you think THIS patient/patient interactions was difficult-evoked a strong emotional response Keep your incident - will be used/turned in during small group

27. Today’s Agenda • Background/Objectives • Critical Incident • “America in Black & White” - Nightline Video • “What I Have Learned About People and Poverty” • Frame: Patient-Centered Care Plan • Eliciting Patient Values/Beliefs • Social Context ROS • Small Group Directions Small Group Discussion • Evaluation

28. Physician and SocietyAmerica in Black & White Disparities in Health Care Travis Webb, MD

29. Preparatory Readings • Carrillo JE, Green AR, Betancourt JR. Cross-Cultural Primary Care: A Patient-Based Approach. Ann Intern Med 1999;130:829-834. • Schulman KA, Berlin JA, Harless W, Kerner JF, et al., The effect of race and sex on physicians’ recommendations for cardiac catherterization. NEJM 1999;340:618-26.

30. Nightline VideoNEJM Cardiac Cath • February 24, 1999 Nightline segment called "America in Black and White: Doctors and Patients." • Consider differences in health care from perspectives of • Patient • Physician • Society

31. Begin Video

32. Today’s Agenda • Background/Objectives • Critical Incident • “America in Black & White” - Nightline Video • “What I Have Learned About People and Poverty” • Frame: Patient-Centered Care Plan • Eliciting Patient Values/Beliefs • Social Context ROS • Small Group Directions Small Group Discussion • Evaluation

33. Social and Economic Factorsthat Influence Health Staci Young, MS Department of Family and Community Medicine Center for Healthy Communities

34. Why Does SES Influence Health? • Health behaviors • Health care quality and access • Social support networks and contacts • Acute and chronic stressors • Neighborhood/community context

35. Quality and affordability of education Quality and affordability of housing Quality and quantity of municipal services Amount of real and perceived crime Access to medical services Affordability and quality of food Safe child care SES - an Individual and Community Phenomenon How is SES experienced at the community level?

36. What Can a Physician Do? • Multiple aspects of economic and social life affect health status. • Physicians can effectively address these issues in broad advocacy, policy, and systems interventions, and in one-on-one patient encounters.

37. Today’s Agenda • Background/Objectives • Critical Incident • “America in Black & White” - Nightline Video • “What I Have Learned About People and Poverty” • Frame: Patient-Centered Care Plan • Eliciting Patient Values/Beliefs • Social Context ROS • Small Group Directions Small Group Discussion • Evaluation

38. Patient Centered Care: The Three Perspective Approach • Patient: • Identify meaning of illness to patient (Kleinman Questions) • Social Context (ROS) • Physician • Society • Be Realistic Patient Centered Care Plan (that will Optimize Patient Outcomes)

39. The Three Perspectives of Patient Centered Care: The Patient, The Physician, Society • PATIENT • PERSPECTIVE • Meaning of Illness

40. Patient Centered Interviewing SkillsEliciting Patient's Values Elizabeth Berdan, M3 Gunnar Larson, MD

41. Self-Awareness & Humility • Examine own values, beliefs, and traditions • Explore ways in which health, illness, & healing are understood by different people • Set aside your own bias in order to deliver effective care to diverse populations

42. Patient Centered Physician

43. Kleinman’s Questions & The Patient Centered Method • Offers structure to the patient-physician interview • An excellent way to begin building your treatment agreement • Kleinman’s questions are often referred to as the explanatory model Kleinman A. Eisenberg L, Good B. Culture, illness, and care: clinical lessons from anthropologic and cross-cultural research. Ann Intern Med. 1978;88:251-8.

44. Kleinman Questions • What do you think has caused your problem? • Why do you think it started when it did? • What do you think your sickness does to you? How does it work? • How severe is your sickness? Will it have a short or long course? • What kind of treatment should you receive?

45. Kleinman Questions Continued • What are the most important results you hope to receive from this treatment? • What are the chief problems your sickness has caused for you? • What do you fear most about your sickness?

46. Challenge Your Assumptions Ask your patient questions… • Assuming you know the answers can lead to errors/misjudgments limiting quality of care

47. Money Questions! 1) What do you think has caused your problem? 2) Why do you think it started when it did? Establishes that you are interested in your patient’s • Values • Time • Ideas

48. Patient-Doctor Connection • Allows you to gauge your patients insight into their health concerns. • Helps to guide patient education on treatment and prevention. • What do you think your sickness does to you? How does it work? • How severe is your sickness? Will it have a short or long course?

49. The Agreement • What do they want to improve? • Are we on that same page? • Where is our common ground in defining your treatment? • What kind of treatment should you receive? • What are the most important results you hope to receive from this treatment?

50. Their Goal Is Your Goal • Help the patient to be the best they can be with THEIR self care efforts • Don’t impose YOUR idealized treatment goals • What are the chief problems your sickness has caused for you? • What do you fear most about your sickness?