Healthcare System and Patient-Centered Care

Early Patient Encounter (EPE)

• Practice of medicine is an art based on science
• Good physicians treat the disease, but great physicians treat the patient who has the disease

Levels of Health Care System

• Primary care: provided by physicians trained for and skilled in first contact; provides continuing care for persons with any health concern
• Secondary care: medical care that is provided by specialists upon referral by a primary care physician; requires more specialized knowledge and skill than primary care physician
• Tertiary care: specialized consultative health care; referral from a primary or secondary health professional; has facilities for advanced medical investigation and treatment (e.g., tertiary referral hospital)

Clinical Encounter

• Can occur in clinics, hospitals, emergency departments, or patient's own house during home visits
• Can also occur virtually through teleconsultations
• Teleconsultations: interactions between a clinician and a patient for providing diagnostic or therapeutic advice
• Examples of services that can be done through teleconsultation:
  • Providing results of investigations
  • Request for sick notes
  • Emergency appointment requests
  • Health promotion (e.g., promoting smoking cessation services)
  • Effective healthcare (e.g., follow-up of depressed or diabetic patients)

Benefits of Teleconsultation

• Convenience for patients (e.g., no time off work)
• Convenience for doctors (e.g., shorter consultation)
• May reduce practice costs (e.g., more doctor time available for other patients)
• Can overcome the issue of a lack of consultation rooms
• Can improve medical access for the disabled

Disadvantages of Teleconsultation

• Absence of non-verbal cues and missed hidden agendas or fears
• No examination findings
• Issues of confidentiality
• Deafness or language can be a big barrier to communication
• Reduced opportunity for health promotion (e.g., blood pressure measurement)
• No opportunity for basic investigations (e.g., pregnancy test or urine dip test)

Teleconsultations in Pandemics

• Safe and effective way to guide the patient's diagnosis and treatment, minimizing the risk of disease transmission
• Enable many clinical services to continue to operate regularly
• Help with management of patients

Patient-Centered Care (PCC)

• Philosophy of care that encourages shared consultation and decisions about management of problems with the patient
• Focuses on the patient as a whole (in contrast to a focus on body part or disease)
• Involves:
  • Transforming the relationship between providers and patients from traditional model to a patient-provider partnership
  • Treating patient as partners, involving them in planning their healthcare
  • Helping the patient become medical decision-makers

The Science of Patient-Centered Care

• Replaces the 'disease-oriented' model with patient's experience of illness, psychosocial aspect, and decision-making with patient and family
• Compares medical (traditional model) and patient-centered model:
  • Patient role: passive vs. active
  • Focus: disease-centered vs. quality of life-centered
  • Recipient of treatment vs. partner in treatment plan
  • Compliance vs. following plan
  • Dominant decision vs. collaborative decision

Steps of Patient Centered Model

1. Exploring both disease and illness

• Disease: abnormality structure, function of body organ/systems including physical and mental disorder
• Illness: how patient feels about being ill, what impact the illness has on patient's function

2. Understanding the whole person

• Person's history, personality development

3. Finding common ground

• Mutual definition of problems
• Mutual definition of goals of management/treatment

4. Prevention and health promotion

• Health enhancement: doctor and patient monitor areas in patient's life that need improvement for long-term physical and emotional health
• Risk reduction and early detection: doctor monitors, recognizes problems, and screens for unrecognized disease

5. Patient-doctor relationship

• Every visit develops care and effective long-term relationship

6. Being realistic

• Time: manage time for maximum benefit of patient
• Realistic about availability of resources

Research on Patient-Centered Method

• Greater levels of patient satisfaction
• Greater levels of doctor satisfaction
• Better patient adherence
• Higher quality of self-reporting
• Fewer malpractice claims
• Greater physician detection
• Has a positive impact on healthcare utilization costs

Clinical Approach

• Includes:
  • History taking
  • Examination (general and specific)
  • Investigation
  • Diagnosis
  • Comprehensive management
  • Follow-up
• Important for decision-making and providing care to patients

History Taking

• Important skill that is essential for decision-making
• Useful for making diagnosis before performing physical examination
• General approach:
  • Introduce yourself
  • Great patient in a friendly relaxed way
  • Confidentiality and respect patient privacy
  • Questioning: simple, clear, open, and leading questions
• Complete history taking:
  1. Personal history: full name, age, sex, address, marital status, occupation
  2. Chief complaint: main reason for visiting a physician
  3. Present history: elaborate on chief complaint in detail
  4. Past history: asking patient if they have any medical problems
  5. Family history: previous similar illnesses in the family
  6. Psycho-social history: smoking, drinking, occupation, education background

Vital Signs

• Reflect body physiological state and provide information to evaluate homeostatic balance
• Include: temperature, pulse rate, respiratory rate, and blood pressure
• Purpose:
  • Obtain data about patient condition
  • For diagnostic, therapeutic purpose

Taking Vital Signs Accurately

• Precautions:
  • Examination room should be quiet and warm
  • Take a minute before starting examination
  • Look at the patient in their entirety
  • Make observations before starting examination

Temperature

• Body temperature: balance between heat production and heat loss
• Stable if heat generated = heat lost
• Normal: 37°C or 98.6°F
• Two kinds of body temperatures:
  • Core temperature (temp of internal organ; remains constant most of the time)
  • Surface temperature (temp of skin, sub-cutaneous tissue, fat cell; rises or falls in response to environment)

History of Acute Sore Throat

• Acute pharyngitis is one of the most common conditions encountered in outpatient clinical practice
• Most cases of acute pharyngitis are caused by respiratory viruses and are self-limited (lasts for about a week)

Investigation of Acute Sore Throat

• Diagnosis is usually clinical
• Evidence of infection can be gained by measuring changing antibody response (ASO titre)

Center Criteria

• 1 point for each feature:
  • Tonsillar exudate
  • Tender anterior cervical lymph nodes
  • History of fever >38°C
  • Absence of cough

Fever PAIN Score

• 1 point for each feature:
  • Fever in the previous 24 hours
  • Pus on tonsils
  • Attends rapidly (e.g., within 1 month)

Referral for Tonsillectomy

• Recurrent acute tonsillitis that leads to missing a lot of school/work (e.g., >7 attacks/year for 2 years)

• Airway obstruction: very large tonsils causing sleep apnea

• Chronic tonsillitis >3 months + halitosis

• Unilateral tonsillar enlargement or recurrent quinsy### Acute Otitis Media (AOM)

• Majority of AOM cases resolve spontaneously

• No need for long-term prophylactic antibiotics in primary care

• Watchful waiting and observing children for clinical improvement is the appropriate strategy for non-severe AOM

• Antibiotics should be provided to children if the infection worsens or fails to improve within 24-48 hours

Referral of AOM

• Children with AOM associated with severe systemic infection
• Children with acute complications like meningitis or intracranial abscess
• Recurrent AOM (three or more ear infections in the last six months)
• Impaired hearing following AOM
• Failure of infection to resolve even after taking previous antibiotics
• Persistent perforation
• Neonates, children younger than 3 months of age, or those with a high temperature of 38°C or more

Hypertension

• Persistent elevation of blood pressure: ≥ 140 systolic and/or ≥ 90 diastolic
• Categories of BP in adults:
  • Normal BP: < 120 mmHg systolic and < 80 mmHg diastolic
  • Elevated BP: 120-129 mmHg systolic and < 80 mmHg diastolic
  • Hypertension: stage 1 (130-139 mmHg systolic or 80-89 mmHg diastolic), stage 2 (≥ 140 mmHg systolic or ≥ 90 mmHg diastolic)
  • Resistant hypertension: BP above goal despite adherence to a combination of at least 3 optimally dosed antihypertensive medications
  • Hypertensive urgency: acute rise in BP without evidence of acute end-organ dysfunction
  • Hypertensive emergency: acute rise in BP with acute end-organ dysfunction
  • White coat hypertension: BP higher when measured in the medical office than when measured at home

Diagnosing Hypertension

• Clinical presentation:
  • Asymptomatic
  • End-organ damage
  • Secondary cause
• Patient evaluation aims:
  • Assess lifestyle and identify other cardiovascular risk
  • Reveal identifiable causes of high BP
  • Assess target organ damage and CVD
• Clinical examination:
  • General examination (BP measurements, weight, and height)
  • Cardiac examination (LVH)
  • Abdominal examination (renal mass, aortic aneurysm)
  • Chest examination
  • Neurological examination
• Investigations:
  • Basic testing (fasting blood glucose, complete blood count, lipid profile, electrocardiogram, etc.)
  • Optional testing (echocardiogram, uric acid, urinary albumin to creatinine ratio, etc.)

Treating Hypertension

• Lifestyle measures:
  • Weight loss (aim for ideal body weight, expect about 1 mmHg reduction in BP for every 1 kg reduction in body weight)
  • Healthy diet (DASH pattern, diet rich in fruits, vegetables, and grains)
  • Reduced intake of sodium (optimal goal ≤ 1500 mg/d, aim at least 1000 mg/d reduction for most adults)
  • Enhanced intake of potassium (aim for 3500-5000 mg/d, by consuming a diet rich in potassium)
  • Physical activity (at least 90-150 minutes/week of aerobic exercise)
  • Moderation in alcohol intake (reduce alcohol to ≤ 2 drinks daily for men, ≤ 1 drink daily for women)
• Pharmacological management:
  • Recommendations for choice of initial monotherapy versus initial combination drug therapy