Understanding the whole patient

Obesity, the epidemic affecting two-thirds of the U.S adult population, is complex. Practitioners are well versed on the intricacies and challenges when addressing patients dealing with obesity. However, regardless of its complexity, the way in which we address the issue tends to be simplified. Over-generalized recommendations in terms of physical activity and nutrition are often shared in a finite amount of time. These generalized recommendations have a tendency to make assumptions that diet and exercise are the primary concerns for our patients dealing with obesity. Where we tend to fail is in understanding who our patients are in that moment. What are their emotional, physical and environmental circumstances that will contribute to their success or demise? And furthermore, our recommendations are just that, OUR recommendations. How often, in clinical practice, do we make the patient the expert? Our patients are experts at understanding their own lives. They inherently know what will and won’t be successful, making them best suited to make or assist in decision making affecting their health.

What we propose is a way to perhaps be more effective long term by gaining an understanding in the concept of the patient’s whole life capacity and the implementation of shared decision making in the treatment of chronic conditions.  In other words, understand who the patient is as a person first, rather than viewing a ‘case’ or a ‘diagnosis’ to be prescribed a protocoled treatment.

In this context, we will use the diagnosis of obesity as the chronic condition.

Imagine a new person walks into your facility or practice – what can be determined at a glance?

  • He lives with his grandfather
  • He has weekly meetings with his sponsor for Alcoholics Anonymous
  • He’s a triathlete
  • He has an eating disorder
  • He’s had intermittent debilitating back pain since high school
  • He is power of attorney for his sister
  • He has a manager who uses bullying and manipulation as strategies to coerce her staff
  • His biggest fear is that his stepchild will not have his seizure medication

 Maybe one of these is accurate; maybe several or all of the statements are true.  So what? In order for him to be successful in managing whichever treatment plan prescribed, his circumstances and values must be considered.  As providers, we have an obligation to consider the following: “Before [I] make recommendations or prescribe medications, how do I understand my patient’s capacity?” This does not have to equate to less efficiency or grossly increased amounts of time spent with your patients (unless such resource is available). However, some up-front work will need to be done, which in our case study has indicated improvement in long-term patient quality of life and life satisfaction.

How much preparatory work? Practitioners who have used the ICAN Tool have noted the tool takes approximately 2-3 minutes for the patient to fill out. How often is a patient waiting in a room or office between care givers during an appointment? This tool could fit nicely in that space. ICAN affords the patient several moments to reflect on what is going on in the complex contexts of life in addition to managing a chronic condition.

Reviewing the Cumulative Complexity Model, we recall the burden of treatment is worsened by things in health care such as disease specific guidelines and quality targets, multiple treatment plans that are misdealt with, monitoring and tests, limited care prioritization and poor care coordination; the patient shoulders workload within a limited capacity which is influenced by scarcity and the burden of illness, which in turn impacts abilities and outcomes. When outcomes are missed, workload increases, and treatment burden becomes more unsustainable.

Certainly, this is demanding work – for both patient and the healthcare team.  How do we sort this out?  We posit that the investment of time using the ICAN tool early on in treatment offers a comprehensive look at the complexity factors. The use of the ICAN tool as a functional discussion aid, or communication tool, allows comfortable and often organic information exchange without adding to the time-burden or barrier of the provider. Remember: We do not have to address every point!

Whether you use this shared-decision making tool or another similar tool, the concept of learning about the patient’s life is critical.  As a provider, you can take highlights that are most important or identify where your patient has the most confidence to change into consideration when prescribing – Rx doesn’t have to be a pill or procedure. Work with patient to design a ‘next step’.

Review of key terms:

  • Burden of Symptoms; Burden of Illness: The Cumulative Complexity Model
  • Workload encompasses everyday life: The demands on the patient’s time and energy, including demands of treatment, self-care, and life in general.
  • Capacity concerns ability/skills to handle work (e.g., functional morbidity, financial/social resources, literacy/language), readiness to change, social support, beliefs
  • Workload-capacity imbalance is when workload exceeds capacity – this drives patient complexity. Treatment and illness burdens serve as feedback loops, linking negative outcomes to further imbalances, such that complexity may accumulate over time.
  • Complexity: A dynamic state in which the personal, social, and clinical aspects of the patient’s experience operate as complicating factors – factors which appear and accumulate over time, interacting with each other in emergent and cyclical ways.

Submitted by Nicole Burow and Jennifer Zundel

nicole-and-jen

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