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Class 2, 12.09.2012Atatürk University Medical Faculty

Contextual CareContextual Care

Zekeriya Aktürk, Prof.zekeriya.akturk@gmail.com http://aile.atauni.edu.tr

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– Discuss consequences of contextual errors in medicine– Discuss health literacy and its relationship with

contextual care/ 262

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/ 263

• Work schedule very hectic

• Couldn’t work 3 days because 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 alcoholism/ 264

• Physical exam normal

• Liver transaminases are slightly increased

• Doctor asks to discontinue alcohol for 2 weeks

• Jackie returns to doctors office to discuss the tests

• Her abdominal pain is markedly improved

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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

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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

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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/ 268

Proximal Context

• Family

• Finances

• Education

• Employment

• Leisure

• Social supportThese issues are looked at, not as isolated facts, but in terms of

how they affect the patient with the illness/ 269

Distal Context

• Community – extended family, resources needed

• Culture• Economics• Healthcare system• Sociohistorical issues• Geography• Ecosystem

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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 (elements of a patient’s environment or behavior that are relevant to their care, including their economic situation, access to care, social support, and skills and abilities). In contrast to biomedical errors, which are not patient-specific, contextual errors represent a failure to individualize care.

/ 2611Weiner 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

• Physicians probed fewer contextual than biomedical hints.

• They provided error-free care more often in the uncomplicated encounters (73%) than in the biomedically complicated (38%), contextually complicated (22%), or biomedically and contextually complicated (9%) encounters.

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• 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!

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• “Well, yes, you are taking the pills, Arden. But how are you taking the pills?”

• “I take the blue pill on one day, the white one the next, 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.”

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• In the solemn privacy of the examination room, I have asked my patients all manner of intimate questions—about their sexual orientation; illicit drug use; income and the affordability of medications; marital infidelity; the possibility of felonious behavior, as it might have related to guilt and depression; or of wifebeating and the abuse of children— but I have never in my recollection asked a patient whether he could read or write.

• Yet 1% of Americans are illiterate, and 30% to 40% are estimated to have inadequate or marginal health literacy

/ 2617LaCombe MA

• It is estimated that 50% of Americans read so poorly that they cannot properly read prescription drug labels and 3 of 4 people on welfare cannot read at all

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LaCombe MA. Contextual Errors. Annals of Internal Medicine 2010;153(2):126-127

Health Literacy

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http://www.annfammed.org/cgi/reprint/3/6/514

Scoring of “The newest vital sign”

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1. If you eat the entire container, how many calories will you eat?

2. If you are allowed to eat 60 g of carbohydrates as a snack, how much ice cream could you have?

3. Your doctor advises you to reduce the amount of saturated fat in your diet. You usually have 42 g of saturated fat each day, which includes 1 serving of ice cream. If you stop eating ice cream, how many grams of saturated fat would you be consuming each day?

4. If you usually eat 2500 calories in a day, what percentage of your daily value of calories will you be eating if you eat one serving?

5. Pretend that you are allergic to the following substances: Penicillin, peanuts, latex gloves, and bee stings. Is it safe to eat this ice cream?

6. Why or why not?

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Also the availability of health resources are not same in all regions

• The number of health personnel is less in rural areas and small cities compared with urban and large cities.

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Comparison of EU Average, WHO European Region Average and Turkey for the Number of Physicians per 100,000 people

Akdağ R (Ed.) HEALTH TRANSFORMATION PROGRAM IN TURKEY PROGRESS REPORT 2010 Republic of Turkey, Ministry of Health Publication No: 807

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Comparison of EU Average, WHO European Region Average and Turkey for the Number of Practitioners per 100,000 people

/ 2625The number of Physicians per 100,000 People in European Countries and Turkey

Summary

• Explain the importance of contextual care in family practice

• What is the approximate percentage of giving correct health service in case of a contextual error?

• What is the importance of health literacy in giving health services?

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