PREVENTIVE MEDICINE Prelims Lecture 1-3

PREV MED Lecture 1: Impact of Illness (Dr. Oczon, July 2015)  Centripetal vs centrifugal phases
EFFECTS OF ILLNESS  Goal: getting on in life without abandoning sick
 Fear of terminal illness member
 Disfigurement  Can bring about mistrust and hostility towards
 Decrease ability to function doctor
 Dependence  Usage of own feelings of guilt and anxiety
 Financial  Arising from fear that they did not act upon the
 Hospitalization symptom soon enough
 Financial disruption of daily act; work, friends, leisure  Issue on legitimacy of symptoms - suspected
 Role reversal, income lose, danger of transmission malingering patients (patients pretending sick
 “one patient is sick, the whole family suffers” even if without illness)

OUTCOME OF IMPACT OF ILLNESS 2. Stage 2 reaction to diagnosis - impact phase

 Affects all family members  Physician's disclosure of diagnosis based on clinical
 Induce family crisis -> disequilibrium judgement
-Rate at which the family recovers and the level of -amount of info patient can absorb given his present
functioning during and after the crisis are indications of level of anxiety (how much the patient want to know,
family health do not bombard patient with knowledge)
 Centripetal (support towards patient) vs centrifugal (away  Serious diagnosis
from patient) -patient and family may not be able to receive much
 Flexibility vs inflexibility info
- How family respond to normative and non-normative -give small dose of info over time
 Enmeshment or disengagement  Disease and appropriate treatment
 Symptom carrier concept/triangulation -terms that patient can understand, avoid medical
 Interaction between type of illness and life cycle stage jargons, slang words and euphemism
- Acute or chronic disease
Emotional plane
A FAMILY PHYSICIAN  Reaction of patient to diagnosis (denial, anger,
 Coping mechanisms depression, acceptance)
 Adaptability (flexibility)  Disbelief and anxiety
 Attitudes may hinder or help to adapt in a healthy way  Anger and depression
 Focus on the patho  Acceptance and accommodation
 Look for the strength and potential on each patient and -important in the implementation of therapeutic
family member plan

STRESS-ILLNESS-FAMILY (Engle) Cognitive plane

 Stress frequently follows illness  Tension and confusion
 Family support protects one from stress  Probable lack of capacity for problem solving
 Illness has an impact on the family  Eventual acceptance of diagnosis
 Family has an impact on illness -enable to mobilize resources
-family should be helped to anticipate such
ILLNESS TRAJECTORY feelings
1. Stage 1 onset of illness -make realistic efforts to relieve self-blame
through careful explaining of etiology
 Onset of symptoms
 Prior to contact with medical care providers
3. Stage 3 major therapeutic efforts
 Medical beliefs and previous experience provide
 Most challenging and rewarding part of medical
influence to meaning of illness
practice
 Acute vs chronic
 Physician deals with multiple variables
 Psychological state (patient and family)
Acute serious illness/death
-Beliefs, cost of treatment, lifestyle, cultural
 At what life cycle did it happen? It will affect
characteristics
coping mechanism
-Stressful effect of hospitalization (surgery)
 "Out-of-phase" phenomenon
 Determine choice of treatment and alternative
 Breadwinners and mothers - upheaval of rules  Educate and assure patient
and roles
 Flexibility and openness Acute (stroke)
 Short time to adjust
Chronic illness - Chronic phase
 Requires rapid mobilization of crisis management
 Struggling to have a normal life despite abnormal skills
circumstances
 Tolerate stress, highly charges emotions
 Dealing with fatigue
 Exchange clear defined roles flexibly
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PREVENTIVE MEDICINE Prelims Lecture 1-3
 Must solve problems efficiently  Anxiety or depression
 Substance abuse
Chronic/gradual  Parent-child problems
 Allows more time to adjust  Marital and sexual difficulties
 May increase strain in family - increasing task
 Lead to exhaustion - caregiver fatigue What are the guidelines in convening family meeting?
 Involve family in the patient's care as early as possible
4. Stage 4 early adjustments to outcome - recovery  Routinely ask if any family members came with them and
 Return from the hospital invite them in for part of the visit
 Gradual movement - sick role to some form of  Be positive and direct about your need to see family
recovery or adaptation - tell your patient that you expect them to come and
 Adjustments with relationship within the family explain that it is a routine procedure
 Emphasize importance of family as resource for caring for
Anticipated outcome patient
 Return to full health - family’s help and opinion are needed
  Stress benefit of a family meeting
 - acknowledge that the problem affects all family members
 Give specific instructions to the patient on who to invite
(Sobrang bilis maglipat ng slides ni doc kaya hindi ko nakopya yung and how to invite them
tatlong anticipated outcome, kung nakopya niyo please share na lang )
What is family counseling?
5. Stage 5 adjustment to permanency of outcome  Intervention involving at least 2 members of the family, the
 Second crisis patient and another member
 Family realizes permanent disability or death  Also means family psycho-education
-focuses on helping the family cope effectively deal with
Red flags illness
 Injury that alters body image -it assumes that the family is healthy and is doing its best to
 Excessive reaction to an illness cope with the illness
 Somatization  If the family is dysfunctional more sophisticated model is
 Suicidal ideation needed
 History of prior psychotic episodes  2 key elements
 Alcohol or drug abuse (1) Education - provides specific guidelines for illness
 Scapegoating of family member management and assistance with problem-solving skills
 History of poor coping mechanisms (2) Psychological support – provides empathy and
opportunity to share feelings, and assistance to the family’s
 All family have dysfunctions, severe illness cam make the efforts to cope by expanding family's social network
dysfunction more pronounced
 Attend to needs of the family because they are our closest allies Steps in family counseling:
in the care of our patient  Key principle: be neutral
 Give each member a time to speak and be heard
PREV MED Lecture 2: The use of ALS in family meetings: CEA method  Direct important questions to each family member present
(Dr. Oczon, July 2015)  Reflect their thoughts and feeling before proceeding to the
Family medicine practice is patient centered, family focused, next question
community oriented  Doctor should be a directive facilitator and nondirective
listener
When to convene the family? -allows doctor to elicit psychosocial and biomedical data
 No strict criteria -gives the doctor the opportunity to explore the emotional
 When physician feels that it would be helpful for the impact of illness on the members of the family
patient
1. Discuss clinical problem
Situations when family member should be routine:  reason for consult, medical history, PE
 Hospitalization 2. Define the clinical problem (catharsis)
 Routine obstetrical and well-child care  Explore patient's and family's health understanding
 Serious chronic illness  Identify the ECM
 Terminal illness and death  Sample questions for patients:
-what do you call you illness?
Consider convening family members when: -what do you understand about your illness?
 Serious illness -what do you think has caused the illness?
 Compliance problems  Probe or reflect the feeling of the patient and family
 Poor control of chronic illness member (no “why” questions)
 High utilization of med service by an individual or family  Sample question for patients:
 Somatization -What does you sickness do to you?
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-What can you no longer do that you want to do?
-How do you feel about your illness?
-How does your family react to you because of
your illness?
-How do you feel about their reaction?
 Sample questions for family:
-How does his sickness affect you?
-How do you feel about his sickness?
 Sample questions for both:
-What do you think will happen to the illness in
the future?
-What do you fear most about the illness?
-What is the worst thing that could happen?
3. Correct misperception (educate)
 Share your findings with the patient and the family
 Address immediately the ECM of the family
4. Address patient's problem (action)
 address ECM regarding treatment
 Sample questions for both:
-how do you feel about the treatment?
-what important results do you expect?
 Sample question for patients:
-what might make the treatment difficult for you
to follow?
-what do you like your doctor to do for you?
 summarize misperception and correct them starting
with the ones that upset them most emotionally
 involve the patient and family in the management
plan, ask them to state what they need from each
other
 Sample questions for patient:
-what would you like your family to do for you?
 Sample questions for family:
-what would you like him to do for you?
 Come to agreement about the things they will do for
each other in order to meet each other's needs
 Set treatment plan including tasks of patients and
family members
5. Closing and follow up
 do feelings check
-ask after the discussion, how are each of you feeling
right now?
-if upsetting or negative feelings still remain you can
decide to deal with it immediately or include it on the
agenda for the next meeting
 set specific time and date for follow-up
Tip: Active listening skills are applied throughout all phases of the
model to correct misperceptions and to provide emotional support to
all family members without sacrificing neutrality
PREV MED Lecture 3: Breaking bad news and the challenge of
communication (Dr. Oczon, July 2015)
Breaking bad news
 A potential cause of anxiety for healthcare professionals
 Source of distress, dissatisfaction, and complaint from the
public
 Not an isolated skill but a particular form of communication
 Communicating with people is a basic human tool and
forms the backbone of our profession
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Prelims Lecture 1-3
Bad news: definition
 Any news that drastically and negatively alters the patient's
view of his or her future
 It is not only about terminal or incurable illness, death and
dying
 Many factors influence the perception of the news making
it bad for a particular person at a particular time
 News maybe bad for the giver as well as for the receiver
What makes bad news bad?
 Previous experiences
 People affected
 expectations or hopes
 Anxiety about treatment
 Uncertainty about the future
 Financial implications
 Opinions and views of significant people
Impact of manner of delivery
 Setting
 Demeanor of the giver
 Words used
 Time allotted
 Phase of discussion
 One or two way exchange
Importance of communication skills
 Great importance should be given both at under and
postgrad levels to teach and learn skilled communication
for all situations
 All doctor irrespective of their specialty should be trained
to be skilled communicators
Why is it so difficult?
 The main goal: to make things better and certainly not to
do any harm (primum non nocere)
 There is a risk of causing great upset, hurt and distress to
recipients which also cause distress to the giver
What are the difficult situations?
 Talk after port-operative diagnosis of malignancy is made
 Cases where death is imminent
 Sudden deaths
 Patients are young esp children
 If there is "no hope"
 Patients or relatives are breaking down
 Patients are in denial
 Patients are previously misinformed
Factors making breaking bad news difficult
 Fear of hurting or upsetting the receiver
 Discomfort by being with the people who are distressed by
the bad news
 Fear of being blames
 Feeling of failing the patient
 Anxiety over how the patient would respond
 Worry over the possible questions of the patients
 Possibly having to admit the one doesn't know all the
answers
 Awareness of lack of knowledge
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PREVENTIVE MEDICINE Prelims Lecture 1-3
 Feeling of inadequacy and incompetence in handling such
sensitive human interactions
 Uncertainty of how to react in front of the receiver

Approach of doctors
 Withholding info
 Soften the blow
 Use euphemisms

Why do we do it?
 Patients have the right to any information we have so that
they may be empowered to take an active part in decision-
making
 Doctors have moral, ethical and legal duty to inform them

Doctors should remember

 Not all patients would want active involvement in decision-
making
 We must not force patients into making decisions
 We should not assume that they have the desire for non-
involvement

Strategy for breaking the bad news: SPIKES

SETTING
 Privacy
 Involve significant others
 Sit down
 Look attentive
 Listening mode
 Availability

PATIENT'S PERCEPTION
 Find out how much the patient knows

INVITATION
 Find out how much the patient wants to know

KNOWLEDGE
 Share info
 use same language as patients
 give info in small chunks

EMPATHY
 Not a skill but an attitude
 Listen for and identify the emotion
 identify source of emotion
 Respond to thoughts and feelings
 Identify misperceptions
 Normalize feelings

STRATEGY/SUMMARY
 Educate, summarize, concretize plan of action
 Ensure patient understand the information
 Outline a step-by-step summary
 Clarify, follow-up

Catharsis = SPI
Education = KE
Action = S

Before you tell, ask first.

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