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By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
Like all days working with the Portland Hotel Society (PHS), I started my day with focused medical learning objectives (I read over all of my extensive notes on how to prepare for and perform the perfect Pap) and came away feeling a mixture of overwhelm, curiosity, and passion to continue to provide care to marginalised people. While running a Pap clinic today (I say that because there was no attending physician present, just me), I learned of one particular woman's history involving significant physical abuse and associated emotional trauma that occurred within the environment surrounding the PHS clinic. I think PHS is amazing in how it brings access to primary care to the people of the Downtown Eastside (DTES), but I hadn't thought about how patients who no longer live and work in the DTES may re-live trauma every time they return to the DTES for ongoing primary care. Needless to say, I was very intentional about obtaining informed consent before the Pap test, with extra sensitivity to explaining why we perform Pap tests, the details of the procedure, and associated risks (physically, potentially a bit of vaginal spotting and pelvic cramping). I also gave her the opportunity to ask any questions, and let her know that if ever during the procedure she was feeling uncomfortable, we could always stop. During the procedure, I kept her informed by explaining what I was doing as I was doing it, and continued to check in to ensure she was comfortable (as comfortable as a Pap test can be, anyhow). The first principle in medicine is First Do No Harm, and in patients with a history of trauma, taking precautions to prevent re-traumatization is an important aspect of providing patient-centered care. After the Pap smear was all done, we discussed the possible transfer of her primary care to another low-barrier clinic situated outside of the DTES, but this was mostly kept as a conversation for another day given the multitude of other things that took precedence at this visit. Recently (aka from 8 am yesterday to almost 4 in the morning - we had a deadline to meet), my resident colleague and I were working on a literature review on the risk factors, protective factors, barriers and facilitators to treatment, and recommendations to promote better care of refugee women with peripartum depression. I was over it when I went to bed in the wee hours last night, but it was at the same time such a good learning experience, and today I was prompted to look to the literature to see what has been published regarding trauma that women have experienced living in the DTES. I found this informative article entitled, "'Like a lots happened with my whole childhood': violence, trauma, and addiction in pregnant and postpartum women from Vancouver’s Downtown Eastside" by Torchalla et al. (2015) as published in the open access Harm Reduction Journal. If you are at all interested in the peripartum experience of marginalised women, I recommend reading it. It also drives home pretty well perfectly the reality of this learning objective and why it matters for primary healthcare providers to understand and critically analyze the environments within which all patients work and live. The social determinants are more powerful than the prescriptions I pen.
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By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient's cultural and gender contexts, will be able to...
Today I received an evaluation from my month rotation on the Family Practice Teaching Service at St Paul's Hospital. Feedback to check off some of the above items include:
I think I milked the feedback for all it was worth and linked it to as many learning objectives as I can ethically feel okay with! By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
Chronic Disease Key Feature 4: In patients with chronic disease, actively inquire about:
Phase: History Difficult Patient Key Feature 3: In a patient with chronic illness, expect difficult interactions from time to time. Be especially compassionate and sensitive at those times. Skill: Patient Centered, Professionalism Phase: Treatment, Follow-up Key Feature 4: With difficult patients remain vigilant for new symptoms and physical findings to be sure they receive adequate attention (ex: psychiatric patients, patients with chronic pain). Skill: Selectivity Phase: Hypothesis generation, Diagnosis Disability Key Feature 3: In patients with chronic physical problems (ex: arthritis, multiple sclerosis) or mental problems (ex: depression), assess for and diagnose disability when it is present. Skill: Clinical Reasoning, Patient Centered Phase: Diagnosis, Hypothesis generation Key Feature 4: In a disabled patient, assess all spheres of function (emotional, physical, and social, the last of which includes finances, employment, and family). Skill: Patient Centered Phase: History Key Feature 5: For disabled patients, offer a multi-faceted approach (ex: orthotics, lifestyle modification, time off work, community support) to minimize the impact of the disability and prevent further functional deterioration. Skill: Patient Centered, Professionalism Phase: Treatment Multiple Medical Problems Key Feature 4: Given a patient with multiple defined medical conditions, periodically assess for secondary depression, as they are particularly at risk for it. Skill: Clinical Reasoning Phase: Hypothesis generation, History Key Feature 5: Periodically re-address and re-evaluate the management of patients with multiple medical problems in order to:
Phase: Treatment, Follow-up Stress Key Feature 1: In a patient presenting with a symptom that could be attributed to stress (ex: headache, fatigue, pain) consider and ask about stress as a cause or contributing factor. Skill: Clinical Reasoning, Communication Phase: Hypothesis generation, History Key Feature 2: In a patient in whom stress is identified, assess the impact of the stress on their function (i.e., coping vs. not coping, stress vs. distress). Skill: Patient Centered Phase: History, Diagnosis Key Feature 3: In patients not coping with stress, look for and diagnose, if present, mental illness (ex: depression, anxiety disorder). Skill: Clinical Reasoning Phase: Hypothesis generation, Diagnosis Key Feature 4a: In patients not coping with the stress in their lives: Clarify and acknowledge the factors contributing to the stress. Skill: Patient Centered, Clinical Reasoning Phase: History The first patient I saw in clinic today was the first patient I saw in clinic at the same time last week, a 47 year old female who had an extensive relationship with chronic pain. Over the years, she had trialed a significant number of medications and alternative therapies to alleviate her pain, but her pain was tenacious. During my first visit with her last week, after confirming that her pain was indeed unchanged over the last many years, and after confirming for myself there weren't any "red flags" in her presentation suggestive of more ominous disease, I reviewed her current pain management strategies, including whether or not she was using any non-prescribed substances to cope. Her approach was as chaotic as the shopping bag she brought with the countless concoctions of over-the-counter supplements and herbal remedies, including some that appeared to not be sold on Canadian pharmaceutical shelves. She was speaking very quickly, wanting to tell me so very much about everything, and I think she was probably in anxious distress and having a hard time trying to cope. At the first visit, we reviewed the past history of her chronic pain - all of the previous investigations that were done and all of the specialists she had seen - and what the conclusions were. We then proceeded to clean up her pain medications and reduce them to the ones she felt confident were making a real difference in her pain. And then our time was well up. We ended this visit with an organized regimen of pain medications and a followup appointment to reassess how things were going in one week. And now here we were. She sat down in front of me and after a polite exchange of hellos she gently asked what we should do this week to modify her pain medications. There is so much about chronic pain we have yet to understand. The pathophysiology is still highly theoretical. We are aware of its association with mood disorders and psychosocial stressors, but we do not understand at a level of utilitarian specificity as to why this is the case. Chicken, egg, or both? In any case, no matter how we arrive at chronic pain, we do know that it worsens mood and aggravates social stress, just as mood and psychosocial stress negatively modulate perception of pain. By extension, if I can do anything to improve mood and psychosocial stress, I may alleviate suffering, and the corollary argument also holds that if I alleviate pain I may improve mood and attenuate psychosocial stress, thereby enhancing quality of life. Knowing the connection between chronic pain, mood, and stress, and now that I had the medical facts straight, during this follow-up appointment I decided to explore what was going on in this patient's personal life. As for mood, although she did not think she was clinically depressed and denied active suicidal ideation, it was certainly suboptimal, compounded not only by her pain but by her debt of sleep secondary to her pain. As it turned out, she attributed her low mood to the stresses in her life: her father living overseas was currently admitted to hospital for life-threatening cardiac disease, and her husband was riddled with aneurysms from his aorta to his renal arteries and was awaiting urgent surgery to prevent sudden rupture and possible death. Wow. Suddenly her pain had context, and was only a part of what I felt was infringing on her quality of life. The focus of our conversation shifted entirely away from her pain at this point, and she opened up about her fears of living life without her most significant others as well as her concerns regarding return to work as she felt she needed to prepare for a future with less financial stability, which was already troublesome. I did not have any advice for her anymore, and instead I just sat there listening to her experience with ache in my heart. After she shared the most salient aspects of her personal life stressors and the impact they were having on her ability to function or create disability, we rerouted the conversation to some practical takeaways to manage things for now, with planned follow-up again in one week. We decided that what was best right now was probably not to make any significant changes to medications, and rather to first have follow-up counselling later this week with her psychologist whom she endorsed having a strong relationship with. At this time she was not interested in any support groups or other community supports, but she said she would consider it in the future depending on how things progressed. She had come to the clinic today asking what we should do to modify her pain medications, and she left saying she was happy we weren't making changes to her current medications and that we were instead focusing on other ways of modulating her pain (I think this must have been partly because she had so many futile experiences with inconsequential medication changes over the years and didn't have much faith that yet another medication change would be her solution). As she was getting up to leave the examining room she said, "I'm now leaving here with more hope, and it's what I really need right now." When I first encounter patients with very complicated medical histories, either because of the number or significance (ex: cancer) of the comorbidities, I find myself feeling stunned by the complexity, oftentimes not knowing where to begin or to what depth I should delve under the pressure of time constraints. Indeed, this is how I felt when I first met this patient. In vain, I have felt personally overwhelmed by patients with multiple somatic complaints, serving only to increase my stress without making any difference in quality of patient care. Instead, these feelings ought to serve as internal cues to the fact that if I am feeling overwhelmed, it almost certainly means the patient is feeling this too, and likely with greater whelm. In that midst of overwhelming complexity, taking time to move beyond exploration of the disease process to exploring the illness experience, can, as this patient taught me, be the basis for a restoration of hope, alleviation of suffering, and improved quality of life.  By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
Near the end of medical school I had the opportunity to hear Dr. Danielle Martin, a family doctor from Toronto, talk about her new book, "Better Now: Six Big Ideas to Improve Health Care for All Canadians." I learned about her and her book only when I received a faculty email advertising it, but as soon as I heard she was a family doctor who wrote a book with that title, I knew I had to be at that talk. And I wanted to come prepared, so I literally read her book in one and a half days, as that was the ETA until talk-time. Oh to be a family doctor who is passionate about advocating for system level changes and actually making a difference! *Insert heart-eyed emoji here* When I read over the UBC learning objectives and thought about exploring the first one that is the focus of this blog post, I immediately thought of "Better Now," particularly since the first chapter is all about the "Return to Relationships" that epitomises primary care. I am moved by Dr. Martin's ideas and the way in which she exposes them to readers, and I want to share what I feel are some of the most compelling parts of her chapter on the significance of primary health care. "Good primary care requires a broad knowledge base. It also requires humility, the ability to sit with the discomfort of uncertainty and help patients do the same, a profound respect for the role of specialists, and a deep confidence that a health care provider who knows the person is at least as important to her health as one who specializes in the disease. And when it's well organized and supported, a primary care practice does much more than just take care of the individuals who come through the door. It serves as a connecting point for the entirety of a person's journey through the health care system, and it reaches beyond its walls to improve the health of the community it serves. A provider or group of providers can identify a population for whose health they are responsible and track that population using data, reaching out to engage in prevention and screening efforts. They can monitor and support patients with chronic diseases, and function as the hub for health and social services in the community. When it works, it really works. That's the Big Idea in this section: relationship-based primary care for every Canadian. This means that every individual should have a relationship with a primary care doctor or nurse practitioner. It also means that every primary care group should have good relationships with the rest of the health care system, and with the community in which all are embedded." I'm going to go on because my heart. "In a society that fetishes specialisation and dramatic, life-saving measures, the value of generalism can be overlooked or minimised. This isn't just a Canadian phenomenon. From the United Kingdom to India to the United States, primary care is critically important and yet, paradoxically, often undervalued. There are lots of reasons for this, but one is that as medical technology advances, it can be hard for people to remember that treatment from specialists isn't always better than treatment from generalists. For many kinds of care, including prevention, screening, and the management of chronic disease, treatment from a generalist who knows you is nearly always your best bet. Relationship-based care from a generalist can and should be holistic: as British general practitioner and medical leader Dr. Iona Health has said, 'A death from a non-cardiac cause can be regarded as a triumph for a cardiologist, but all deaths fall within the remit of the GP.' Primary care is also critical to ensuring that our health care system will be sustainable. Systems that focus on good primary care are more cost-effective, more equitable, and deliver higher quality care overall. A big part of the reason for this is that primary care is the best place to help people manage chronic disease. As medical science has enabled an increasing number of people to survive previously fatal problems like cardiovascular disease and cancers, people are living longer and developing more chronic conditions like high blood pressure, diabetes, and heart and lung disease. To have each of these diseases treated by a different specialist (...) is not only time-consuming and confusing for the patient but expensive for the system." And then Dr. Martin ends this chapter with a compelling argument on how the scope of primary health care extends, as it should, beyond the realm of the family physician. "I focus on family medicine because the vast majority of primary care in Canada is delivered by family doctors, and that's likely to continue to be the case. Having said that, primary care is not the sole remit of doctors. Nurses, nurse practitioners, physician assistants, midwives, pharmacists, social workers, dietitians, and a wide range of other providers are increasingly the first point of contact with the health care system. In some communities, people receive nearly all their primary care from nurses with advanced training. And in remote communities throughout Canada's vast north, where there are very few physicians or nurse practitioners, they may receive their primary care from community health workers. There is no magic to an MD degree that makes a doctor the only person suitable for providing high-quality primary care. Other providers play important roles in disease prevention, health promotion, and the treatment of illness. In the case of primary care nurse practitioners, their training enables them to perform work formerly thought of as "doctor" work. I'm not worried that a nurse practitioner or any other provider might do much (or even all) of what I do as a family physician. They're well-trained and capable, and when they bump up against the limits of their expertise, they bring a doctor into the mix - just as I seek other expertise when I hit my own limits. Frankly, there is more than enough work to go around. What matters to me isn't who does the work, but that the work drives primary care to live up to its potential. This means that we can't just look to download tasks onto less costly providers at the expense of relationships, or add more providers to the team without a clear purpose and good evidence that their participation improves the health of the community, improves the patient's experience of care, and saves the system money - the Triple Aim. As a doctor and a citizen I want to know that every primary care provider is prepared to commit to three critical relationships: with patients, with other parts of the health care system, and with the broader population they serve." I want to marry primary health care and live happily ever after with it as it cares for me and all my chronic diseases <3 By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
Dementia Key Feature 6: In patients with dementia, assess competency. (Do not judge clearly competent patients as incompetent and vice versa.) Skill: Clinical Reasoning Phase: Diagnosis Mental Competency Key Feature 1a: In a patient with subtle symptoms or signs of cognitive decline (ex: family concerns, medication errors, repetitive questions, decline in personal hygiene): Initiate assessment of mental competency, including use of a standardized tool. Skill: Clinical Reasoning, Communication Phase: History, Physical Key Feature 1b: In a patient with subtle symptoms or signs of cognitive decline (ex: family concerns, medication errors, repetitive questions, decline in personal hygiene): Refer for further assessment when necessary. Skill: Clinical Reasoning Phase: Referral Key Feature 2: In a patient with a diagnosis that may predict cognitive impairment, (ex: dementia, recent stroke, severe mental illness) identify those who require more careful assessment of decision-making capability. Skill: Clinical Reasoning, Selectivity Phase: Hypothesis generation, Diagnosis Key Feature 3: When a patient is making decisions (ex: surgery/no surgery, resuscitation status) think about the need to assess their mental competency. Skill: Clinical Reasoning, Professionalism Phase: Hypothesis generation Key Feature 4: In a patient with cognitive impairment, identify intact decision-making abilities, as many may be retained. Skill: Clinical Reasoning, Selectivity Phase: Hypothesis generation, Treatment {A bit of preamble context: Today was the first day of my one-month rotation at Three Bridges, a community health clinic with a mandate to serve patients who have been marginalised and underserved in traditional institutions of health care delivery. These may be patients with substance use disorders, without a fixed address, who are single teenage mothers, who are HIV+, who fall within the LGBTQ umbrella, etc.} Three patients I met in clinic today prompted me to consider my ability to assess competency and highlighted my lack of confidence in knowing whether or not I could make the call regarding their decision-making capacity if I was the most responsible physician overseeing their care. One of these patients was an elderly gentleman with moderately severe major neurocognitive disorder (aka dementia) and melancholic depression. His therapy was clearly not optimised, and he was coping rather poorly, but yet he did not want to consider a change in therapy as was being suggested during the visit. I wondered if he was competent to make this decision. The second patient was a 19 year old transgender female (birth-assigned male) who wanted to initiate an application for genital surgery and appeared quite competent to make this decision based on my clinical assessment. But I was unsure of how exactly I could confirm - for a decision with as permanent of consequences as the one being requested - that it was a fully informed one. The third patient was a middle-aged man with a history of query bipolar disorder and alcohol use disorder who appeared hypomanic on assessment and not on any mood stabilisers. He was precontemplative as far as his alcohol use was concerned, with unrelenting alcohol consumption despite liver failure and a recent discharge from hospital for complications of heavy alcohol use. I wondered if he had capacity to make many of the decisions he was making on a day-to-day basis that were causing himself harm. So like a good little resident, I left clinic feeling motivated by the dejection of not knowing another whole chunk of how to be a doctor. As I walked home, I considered what I felt I would need to know to feel confident deciding one way or another if patients have decision-making capacity. When I sat down at home and flipped open my laptop to get to my notes on Capacity & Consent, all I found was a bare and anonymous paragraph that was certainly not my own composition: "For a patient to provide consent they must have the mental capacity or competency (legal equivalent) to provide consent, consent must be given voluntarily, must be informed and must apply to a specific act or set of acts. The ultimate responsibility for ensuring informed choice, mental capacity of the patient to provide consent, and documenting a valid consent rests with the caregiver proposing and providing the intervention." -Anonymous How can I translate this into my day-to-day decision-making in the clinic when I need to know if the patient in front of me has the mental capacity to make a given decision, and how do I know what constitutes me giving enough information so that they can be sufficiently informed to provide informed consent? According to UpToDate (2017), "In the absence of a reason to question an individual’s decision making, adults are generally assumed to have adequate capacity." Fair enough. So what are the reasons that ought to prompt me to question decision-making capacity? I read over the rest of the article, Assessment of decision-making capacity in adults (2017), and came up with a mnemonic I am going to call the 6Ds.
Great! So now I know what patient factors ought to prompt me to think about assessing a patient's capacity when facing the need to make a decision that may impact their health. Now how do I go about assessing the patient's capacity? The UpToDate fairies have provided a succinct and superb table summarising the 4 domains that need to be assessed regarding any decision whenever there is any doubt about patient capacity, or even if there is no obvious reason to doubt patient capacity but the ramifications of the health decision are of increased significance (pay particular note to the instructions beneath the table).  What exactly are the "relevant facts" that must be disclosed to ensure consent is informed?
Per UpToDate (2017) paraphrasing, informed consent necessitates that:
Legally, there are 3 ways in which the courts may decide that a physician has followed through on their duty to inform when obtaining consent regarding a treatment or other medical decision. Considering all 3 of these standards can help provide clarity when considering, for a given medical decision, wether all of the reasonably relevant facts have indeed been disclosed for the decision at hand. Per Informed procedural consent (UpToDate, 2017):
Although I cannot now retroactively seek answers from the patients I encountered today to determine their decision-making capacity, I believe my new approach (see below) based on the above information can provide me with the guidance to determine future patients' decision-making capacity moving forward. I am certain I will have many opportunities to put this to the test. Madalena's (aka UpToDate's) Decision-making Capacity Framework
This all seems like a lot of work, but in practice I imagine it could be done rather efficiently with a bit of practice. And regardless, it is important to put in the work because this is just the ethical thing to do. As UpToDate (2017) summarises: "The benefits of truly informed consent include
In summary "For a patient to provide consent they must have the mental capacity or competency (legal equivalent*) to provide consent, consent must be given voluntarily, must be informed and must apply to a specific act or set of acts. The ultimate responsibility for ensuring informed choice, mental capacity of the patient to provide consent, and documenting a valid consent rests with the caregiver proposing and providing the intervention." -Anonymous *Legal competency decisions are set out by law, in such acts as the Mental Health Act and the Personal Directive Act and Trusteeship Act (actual name varies but with the same idea), which vary provincially in Canada. |
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