BEING REALISTIC

Presented by:
Dr Nini Shuhaida Mat Harun

Supervised by:
Dr Rosnani Zakaria

What does Being Realistic means?

Who: Doctor or patient?
What: History? Physical
examinations? Investigations?
Managements?
Why?? the benefit
When: Exam? Practice?
How?? will be discussed

Moira Stewart

Intro
Patient

Problems more
complex, multifaceted
Many ideas
Many concerns
More expectations

Doctor

Time constrain
Limited resources
Physical & emotional
energy
Teamwork

Being realistic in pt care

Manages resources, especially time and
energy, to provide optimal care for the
patient in the context of whole practice
in the community in which the physician
works.

Canadian Medical Association Journal, April 15, 2003; 168, 8; ProQuest Central, pg. 957

Time & timing

Research has shown that visits in which the pt are active
participants in telling about their illness and in asking
questions are almost identical in length to other visits.
Dont be afraid because your time wont waste by giving
your pt time to talk.
Length of consultation can be as brief as 5 minutes (in UK) ,
12 minutes in Australia.
Recent studies the length of time family physicians spend
with patient has increase by 2 minutes approximately 17
minutes.

(Blumenthal et al.,; 1999, Mechanic et al., 2001 ; Stafford et al.,1999)

 Pt as active participant:
The best use of resources over long term,
Potentially saving the pt from return to other
visit for more accurate recognition of
problems,
Leading to fewer unnecessary tests and
referrals.

All because his problems have been

more appropriately prioritized.

 Not to deal with all problems in every

pt in each visits BUT must able to
recognize when a pt need more time.
How to prioritize pts problem?
Guided by pts expressed concerns, and
The potential seriousness of the
problems. (eg: child abuse, suicidal
ideation, woman abuse, life-threatening
medical situation)

 Must know how to create quickly an

atmosphere in which patients feel heard
and understood and feel their problems
are important.
Essential skills for physicians flexibility
and readiness to respond in a manner that
express both concern and willingness to
work with patient in a future.

IMPORTANT!!!
The doctor needs to acknowledge the pts
concerns.
Depend on time and availability
At the moment, or
Further f/up

If not:
Unnecessary use of resources at subsequent visits
Increase cost of Mx
Pt demand further visits, additional Ix, unwarranted
procedures,
Pt and doctor dissatisfaction

Accessing Resources and

Teambuilding
Not expected to be knowledgeable about
every available resource in community for
each specific group BUT
Must be prepared to learn about the context
in which the pt live and how to access the
appropriate resources.
knowing the key personnel who can
locate, motivate and promote changes.
In other words; works in a team and adopt a
position of shared responsibility and power.

 No one profession can meet all the

pts needs, hence the need to work
together in teams. There are
strengths, but also pitfalls in
teamwork. There are also
misconceptions about what
teamwork is.
McWhinney (1989)

Successful team building

3 approaches:
Coordination (multidisciplinary)
Cooperation (interdisciplinary)
Collaboration (transdisciplinary)

Multidisciplinary
Promotes the achievement of multiple
goals and tasks in health care delivery by
multiple participants.
Disadvantages:
Compartmentalize healthcare delivery
May result in duplication of services or gaps in
service
From patients perspective fragmented care
and confusion about accessing and using
appropriate resources.

Interdisciplinary
Each discipline works independently but in
concert with other members to address
particular pt needs.
Disadvantages:
Tends to be case specific.
Does not ensure integrated team functioning.
Much time and effort may be consumed in
negotiating professional roles and extent of
involvements.
Fragmented care and confusion about service
delivery pt experience.

Transdisciplinary
More flexible and crosses disciplinary
boundaries.
Requires more equitable distribution of
responsibility and power.
Lead to increase comprehensive pt care.
Active involvement of the pt in all phases
of planning and implementing their care
equal participants.

Wise stewardship

Exhibits wise stewardship of limited

community resources: balances need of
individual patients with the needs of the
community
Constantly making a conscious choice in
determining value trade-offs between pts
needs / wants and resources available.

A penny of good communication time may avert a pound

of unnecessary or even harmful spending used to reassure
an anxious patient or substitute for a sketchy history

Goold and Lipkin (1999)

CASE SCENARIO
CASE SCENARIO

Case scenario 1

33y/o Malay lady

G6P5,@34/52 POG
: placenta praevia type IV
FHx: children aged: 12,10,8,5,3
husband: labourer
patient: housewife

 Doctors view: need for admission

afraid risk of bleeding / complications
Patients view: refused for admission
: reason- nobody to take
care the
children
- husband workingunable
to take long leave
: promise will take care
herself

What are you supposed to do ?

Follow patient request ?
How to negotiate with patient ?

To be realistic..
Patient
Time: anytime
available?
Human resources:
anybody available if
need to send her
urgently to the
hospital?
Physical resources:
any transport
available ?

Doctor
Time: anytime available?
Human resources: can ask JM to
do home visit and if encounter
any problem to let you know for
further action
if, patient came to clinic, is it
anybody available to entertain
her?
get advice from O+G team- to
anticipate problem if anything
happen
Physical resources: can provide
clinic phone no, if need
ambulance or further care

If bleeding occur, and patient must be hospitalised.

Who will take care her children??
Husband? Parents? In laws? Neighbour?
All children need to stay at their own
house or go to people that can take care
them?
After discuss ---- decision...

Case scenario 2
70y/o man
History of DM, Hypertension
c/o: swelling over the back for 3 days
a/w low grade fever
O/E: carbuncle over the back, need
saucerization.
T: 37.5C Dxt: 16mmol/L
clinically not septic looking
FHx: stay with wife (70y/o)-stroke,
bedridden,
taking care wife on his own
A son, stay far-have own family

Patient
Refuse for
admission
Nobody take care
wife
Need to wait for
child to come
home

Doctors view
Need for admission
Goal treatment:
saucerization and
diabetic control
If delay can
progress into
sepsis

What are you supposed to do?

scold patient and force him for admission?
ask other colleague to recounsel patient?
ask patient to sign AOR form?
follow patient request? Negotiate?

Being realistic.
Patient
Time: only available
when his child came back
home / other relatives
come to take care his
wife
Human resources:
children/relatives?
neighbour
Physical resources: any
transport available, if
need to come to hospital
urgently

Doctor
Time: can come anytime, if
need hospitalization- arrange
to the nearest hospital
Human resources: MA/nurses
need to remind re :follow-up, if
stay near patients house can
monitor progress
if patient came with sepsis,
early intervention needed, so
need to equip staff to do
resuscitation before further
referral
Physical resources: ambulance
available?
emergency trolley

What we can do if patient still refuse admission after

counseling.
We can give antibiotic for a mean time, but still
advise the patient to come to clinic/ nearest
hospital if condition worsen.
Advise patient to control sugar can increase
dosage / assess compliance
Advise to inform child re: his condition and what
Drs advise and also to inform friends and ask
for help if anything happen.
Give patient open appointment to come to see
you if he change mind.

Conclusions
Let the pt express his problems and ask
questions pt as active participant.
Prioritize the pt illness/ problems.
Address the pts problems in effective and
efficient manner.
Know the key personnel who can locate,
motivate and promote changes team
work.
balances need of individual patients with the
needs of the community.

Referrences
Patient-centered Medicine:
Transforming the Clinical Method;
Moira Stewart, Judith Belle Brown et.
al.
British Journal of General Practice,
October 2005

In the hands of GPs, I have watched the patients

confusion, fear and doubt transform to clarity, relief
and assurance. There is still confusion all around but
there is a time of insight, healing and new positive
energy within the patient to engage the situation.
Without the GP in this role, there would continue to
be more confusion, fear and doubt. With the GP in
this role, sick people recover, sick people find relief
from suffering, some sick people fear less, and some
sick people are filled with hope. This is general
practices precious gift to humanity.
-Moira Stewart-

THANK YOU