Saturday, October 5, 2013

Patient Advocacy: Family Physicians as Patient Advocates
Family Physicians as Patient Advocates
Dr Jaya Bajaj

Advocacy is an important component of the doctor-patient relationship. Family physicians may be a natural choice as patient advocates because of the trust they have built over a long time
I grew up in a small town and had the privilege of experiencing the kindness of our family doctor. My siblings and I received all our vaccinations at his clinic and he would graciously make home-calls when one of my grandparents got sick. I remember him sitting next to me, reassuring that “everything will be alright” when I got sick during my HSC board exams. When my grandfather developed heart disease, he helped my father arrange medical care for him in the nearest town. He was always available for answering our questions during the long hospitalization of my grandfather. He even travelled to the hospital when my grandfather was getting discharged and discussed the prognosis, discharge instructions; medications etc. with the consulting cardiologist that he then proceeded to explain to my father in simple terms. Any surprise that he took care of three generations in our family?
These are the kinds of family physicians we had until a few decades ago. “patient advocacy” and “patient-centred care” were not the terms I remember being spoken then, but the family physician always put the patient’s interests first. However the last few decades have brought significant changes in medical care. The introduction of powerful medications, sophisticated imaging procedures, and expensive diagnostic techniques has meant that healthcare delivery has become a very complex process. Patients don’t always consult family physicians first and many want a specialist consultation even for minor ailments. The fragmentation in healthcare has actually led to a drop in the quality of care and there is an increasing need for patient advocates to protect the patient’s best interests and ensure the delivery of safe care. This chapter looks at the role of family physicians as patient advocates.

My favourite description of family physicians is by Dr. Gayle Stephens, “Family physicians know their patients, know their patients’ families, know their practices, and know themselves.” Stephens describes patient management as “the quintessential skill of clinical practice” and “the area of knowledge unique to family physicians.” He distinguishes management from treatment, saying managing implies, “alleviating most effectively the total impact of illness upon that person.”
Family physicians are usually the first point of contact during an illness. Unlike other medical specialists, who focus on specific diseases or organ systems, family physicians specialize in seeing patients who may present with multiple problems that are not slotted into a particular system. Ideally, family doctors have a long-standing relationship with their patients and therefore have a sound basis of understanding the patient’s perspectives and needs, so they can offer options that meet their best interests. They have a holistic perspective, because they are taught to put the patient first. Globally, healthcare systems that are considered to provide the best quality care are the ones with strong primary care, driven by family physicians.
When should family doctors act as patient advocates?
Recently, one of my elderly relatives had to be hospitalized. In his mid 50s, he had been in good health except for mild hypertension (high blood pressure) that was well controlled with medicine. He had several episodes of diarrhoea overnight which he attributed to dining outside. He had his morning tea and breakfast and took his medication as he always does. Yet feeling sick, he decided to take the day off, something he rarely did in the last couple of decades, and never for health reasons.
This surprised his spouse as well as concerned her. A couple of hours later she noticed that he looked pale and was unable to stay awake. She rushed him to a nearby hospital, where he was diagnosed with acute renal (kidney) failure, atrial fibrillation (irregular heartbeat), hypotension (low blood pressure as a result of diarrhoea), cellulitis (soft tissue infection) in the leg and electrolyte abnormalities (low sodium) leading to confusion. He was given intravenous fluids and was examined by an internist and a surgeon, who recommended that he be moved to a tertiary care centre because of the complexity of his illness. He was immediately shifted to a tertiary care centre in a metropolitan city. Needless to say, the family was in a state of shock over the developments of the past 24 hours.
At the tertiary care centre, my relative was examined by an army of healthcare professionals: internist, surgeon, and cardiologist, nutritionist, physiotherapist, wound care specialists etc. His blood pressure medicine was stopped and he had to be started on a new set of medicines, mainly antibiotics, medicine to regulate his heart rate, blood thinner, antacids, multivitamins etc. Over the next two days, when his infection subsided, he was no longer confused, yet he complained of a persistent headache.
After multiple requests, the nurse came around to check his BP which was quite high as the medical team had forgotten to restart his BP medicine. He was discharged home with half a dozen medicines and instructions to follow-up with three doctors who had seen him during his hospitalization. In retrospect, he could have been spared this ordeal, had his family physician been a part of the medical team. He would have added value by:
Eliminating the medical jargon
Healthcare has a language of its own. Many times healthcare professionals don’t realize how insidiously medical acronyms become a part of their normal lingo. A family doctor who is aware of his patient’s health literacy can explain the diagnoses in a language that the patient can understand, and prepare the patient for the next course of action. An important part of this role is helping to curate and interpret the almost overwhelming amount of information available to patients today, thus helping them make intelligent personal choices for their own care.
Strengthening the diagnostic process
Healthcare has become more complex and fragmented than ever. A family physician can facilitate diagnoses in a timely manner by prioritizing problems. He can educate patients about the best evidence-based treatments available, helping them to make informed decisions about their care. For instance, in the case cited above, the family physician could have picked up the warning signs of low blood pressure and helped coordinate the future course of action.
Communicating the diagnosis to the family
If the patient so desires, the family doctor can explain to the patient’s family or care-givers details about the disease and the available treatment options. He can help patient select the best treatment options available by exploring the resources and constraints of the patient and the care-givers.
Offering resources to the patient and family
A serious medical illness can be terrifying and disruptive to the patient, as well as the patient’s family and care-givers. A family doctor can help patient and family members tap into community resources. These could be local support groups, expert patients, health libraries, reliable online information on patient’s illness, and information on financial grants, as well as information on centers offering such resources.
Researching and choosing appropriate a healthcare team
Family doctors can help patients find the best possible healthcare team for their needs, by keeping in mind the patient’s personal preferences and beliefs.
Exploring alternate treatment options with patients
Patients are often the first ones to discover “new treatment options” they want to explore. Sometimes, patients are not able to discuss these with the specialist, simply because of a lack of access to the specialist, many of whom are unapproachable and inaccessible. A family doctor can help the patient sift through relevant information and coach the patient on effective ways of sharing the information with the specialist. In the case of my relative, the patient was offered warfarin as a blood thinner for his heart condition. What the specialist was not aware of was that the patient, who lived in a small village, would not be able to get the basic monthly lab tests that are important for monitoring patients on warfarin. A family physician who had this contextual information on the patient, would have brought this to the specialist’s attention, and suggested an alternate course of action.
Ensuring continuity of care

An engaged patient-doctor team is needed to ensure continuity of care. A huge proportion of medical errors can be attributed to communication breakdowns because of healthcare silos. A family doctor can function as a team leader, coordinating care between patient, family members, care-givers and multidisciplinary healthcare providers, thus ensuring clear communication and continuity of care. This is very important to providing patient-centered care. Sadly, most medical students are never exposed to these concepts during their medical education.

The above is an extract from Dr.Aniruddha Malpani's book : Patient Advocacy - Giving Voice to Patients
The book launch will take place on Saturday, 16 November 2013 at Hall of Harmony, Nehru Center, Worl, Mumbai - 400018 during the 4th Annual Putting Patients First Conference.

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