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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...
Crisis Key Feature 1: Take the necessary time to assist patients in crisis, as they often present unexpectedly. Skill: Patient Centered, Professionalism Phase: Treatment Key Feature 6: Inquire about unhealthy coping methods (ex: drugs, alcohol, eating, gambling, violence, sloth) in your patients facing crisis. Skill: Clinical Reasoning Phase: Hypothesis generation, History Key Feature 11a: When dealing with an unanticipated medical crisis (ex: seizure, shoulder dystocia): Assess the environment for needed resources (people, material). Skill: Clinical Reasoning Phase: Treatment Stress Key Feature 4b: In patients not coping with the stress in their lives: Explore their resources and possible solutions for improving the situation. Skill: Patient Centered Phase: History, Treatment Key Feature 5: In patients experiencing stress, look for inappropriate coping mechanisms (ex: drugs, alcohol, eating, violence). Skill: Clinical Reasoning, Communication Phase: Hypothesis generation, History I am currently working at an HIV primary care clinic. What this means is that all of the patients attached to this clinic have HIV, but they present to this clinic to deal with all of the usual general medical concerns that any person may have along with their HIV care. With advancements in recent years in the diagnosis and management of HIV, this means that most patients here are actually quite stable when it comes to management of their HIV (most patients have undetectable viral loads and protective CD4 cell counts). Their lives are still certainly complicated by it, as they need to be diligent about taking their daily medications and receiving regular followup medical care, which really is not unlike care for most chronic diseases. Today in the HIV clinic I met a 56 year old man who was doing perfectly well from an HIV medical care perspective. However, he was coping with a lot of financial stress in his personal life. He had recently been hired again a few months ago after losing his job for many more, and he was having a very hard time making ends meet. He presented with concerns about depressed mood or feeling "subdued," which was how he described it. Upon assessment, he was clearly having a relapse of Major Depressive Disorder, which he had been in remission for and off antidepressants for over 3 years. Clearly, financial stress was a precipitant for this active episode of major depression, so along with treating the depression, my role today was to help him address the reasons underlying it. I screened him for other interrelated comorbidities and coping behaviours that can have negative repercussions, such as substance use, and asked him about the consequences that his depressed mood was having in his life, to assess for complicating features. Experienced with having gone through a Major Depressive Episode before, he had a lot of insight this time around and presented to clinic before things got too far out of hand. So many patients present for medical problems that are protracted consequences of the social determinants of health, and to address them, we really need to address those determinants. And it's not easy, particularly when you think about how deep their influence goes, such as impact of adverse childhood experiences (ACEs) and the pervasiveness of the impact. Fortunately, here at the well-supported HIV clinic, we have access to a Registered Social Worker on our team to assist patients with the many financial and other realities of life that have immense repercussions on patient wellbeing. While this doesn't eradicate all negative social determinants of health by any means, it helps to foster a culture of resilience whereby patients are empowered to live lives with better health and quality of life. One of the supports that I think is fantastic is the nurse who triages patients who present to the HIV clinic on an urgent basis, without having booked appointments. This means that patients with urgent needs can be seen by a doctor that same day, while those with less urgent needs can get booked for an appointment within the next few days. Although the patient may be seen by one of the doctors working in the clinic that day, and this person is often not their primary care physician, the information about the patient is in their chart, and so there is more continuity of care than at a walk-in clinic. (There may also be a need for more specialized urgent care at the HIV primary care clinic rather than a routine walk-in clinic as well, since treatment decisions may be influenced by the presence and active treatment of the patient's HIV, which many physicians may not have much experience with managing.) The reality is that while many medical issues are best managed in an outpatient setting, and others require emergency medical care, many fall in the grey zone in between, needing so-called urgent care. There is a need to see patients who are having urgent issues not in the Emergency Department when they don't need a high acuity level of care, and ideally by a primary care practitioner who knows them well. Unfortunately, when the health care system is structured with a gap in primary care providers delivering urgent care services, patients have little choice. I think the best option is to have walk-in clinics for those who do not have a family doctor, but ideally attaching these patients at the same time to regular family doctors who can provide routine care as well as urgent care. The primary care clinic just needs to be set up in such a way so as to make that work (ex: in my home family clinic, one doctor every day leaves a certain number of slots open to address urgent concerns). Back to the patient: The gentleman in clinic who I met with today received a referral to meet with the team social worker to discuss how he is currently managing and what his options are moving forward. As a family doctor in the community, I will likely not have the privilege of having a social worker at my fingertips, so it will be extremely helpful for me to become familiar with local resources, especially financial supports. At the same time, it's important to remember that there are social workers in the community who I may be able to refer patients to for extra support. And by setting up my practice so that I can help patients manage urgent concerns I am most likely to be able to do what needs to be done.
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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...
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.  |
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