Medicalisation reconsidered: toward a collaborative approach to care

The concept of ‘medicalisation’ has informed the sociology of health and illness for several decades. Typically, it has been discussed with critical connotations, although some commentators have suggested that it is not unequivocally negative. This paper seeks to clarify the concept, suggests that medicalisation can be both helpful and unhelpful, and identifies the characteristics of beneficial medicalisation. Using data from doctors and patients who are dealing with a refractory, relapsing and disabling condition - Chronic Fatigue Syndrome - we explore the impact of medicalisation in different forms on the participants in the medical encounter. Both doctors and patients were, at times, uneasy about the possibility of a self-fulfilling prophecy through which a medical diagnosis might generate deleterious consequences from a comparatively trivial complaint. However, when such motivations prompted doctors to withhold information (such as a suspected diagnosis), the results were generally increased difficulties for the patient. Whether intentional or accidental, medical dominance in any form consistently generated problems for patients. But when medical explanations were mobilised to enhance the coherence of the patient's experience of symptoms, patients found medicalisation to be helpful. Patients whose doctors took their symptoms seriously gained legitimation which helped them in a range of social relationships. They also received support for their efforts at self-management. Legitimacy, coherence and support are all necessary components for improved well-being, and doctors can supply such assistance even in the absence of unequivocal diagnosis and proven therapeutic interventions.     

Giving voice to the lifeworld. More humane, more effective medical care? A qualitative study of doctor-patient communication in general practice.

Mishler (The discourse of medicine. The dialectics of medical interviews. Norwood, NJ: Ablex), applying Habermas's theory of Communicative Action to medical encounters. showed how the struggle between the voice of medicine and the voice of the lifeworld fragmented and suppressed patients' multi-faceted, contextualised and meaningful accounts. This paper investigates and critiques Mishler's premise that this results in inhumane, ineffective medical care. Using a more complex data collection strategy, comprising patient interviews, doctor interviews and transcribed consultations we show more complex relations than emerged from Mishler's analysis. We found four communication patterns across 35 general practice case studies. When doctor and patient both used the voice of medicine exclusively (acute physical complaints) this worked for simple unitary problems (Strictly Medicine). When both doctor and patient engaged with the lifeworld, more of the agenda was voiced (Mutual Lifeworld) and patients were recognised as unique human beings (psychological plus physical problems). Poorest outcomes occurred where patients used the voice of the lifeworld but were ignored (Lifeworld Ignored) or blocked (Lifeworld Blocked) by doctors' use of voice of medicine (chronic physical complaints). The analysis supports the premise that increased use of the lifeworld makes for better outcomes and more humane treatment of patients as unique human beings. Some doctors switched communication strategies in different consultations, which suggests that their behaviour might be open to change. If doctors could be sensitised to the importance of dealing with the concerns of the lifeworld for patients with chronic physical conditions as well as psychological conditions, it might be possible to obtain better care for patients. This would require attention to structural aspects of the healthcare system to enable doctors to work fully within the patient-centred model.     

Patient empowerment,an additional characteristic of the European definitions of general practice/family medicine

Abstract

Growing evidence supports the inclusion of patient empowerment as a key ingredient of care for patients with chronic conditions. In recent years, several studies based on patient empowerment, have been carried out in different European countries in the context of general practice and primary care to improve management of chronic diseases. These studies have shown good results of the care model, increasing patient and health professionals’ satisfaction, adherence to guidelines and to treatment, and improving clinical outcomes. In 2011, the Wonca European Council included as the twelfth characteristic of the European definitions of general practice/family medicine: ‘promote patient empowerment’. The aim of this paper is to clarify the meaning of 'patient empowerment’ and to explain why family medicine should be considered the most suitable setting to promote it. The inclusion of patient empowerment as one of the essential characteristics of general practice fills a conceptual gap and clearly suggests to the European health care systems a tested model to face chronic diseases: involving and empowering patients in managing their own conditions to improve health and well-being.     

Primary Care Physician Insights Into a Typology of the Complex Patient in Primary Care

PURPOSE

Primary care physicians play unique roles caring for complex patients, often acting as the hub for their care and coordinating care among specialists. To inform the clinical application of new models of care for complex patients, we sought to understand how these physicians conceptualize patient complexity and to develop a corresponding typology.

METHODS

We conducted qualitative in-depth interviews with internal medicine primary care physicians from 5 clinics associated with a university hospital and a community health hospital. We used systematic nonprobabilistic sampling to achieve an even distribution of sex, years in practice, and type of practice. The interviews were analyzed using a team-based participatory general inductive approach.

RESULTS

The 15 physicians in this study endorsed a multidimensional concept of patient complexity. The physicians perceived patients to be complex if they had an exacerbating factor—a medical illness, mental illness, socioeconomic challenge, or behavior or trait (or some combination thereof)—that complicated care for chronic medical illnesses.

CONCLUSION

This perspective of primary care physicians caring for complex patients can help refine models of complexity to design interventions or models of care that improve outcomes for these patients.     

Illness behaviour and patient satisfaction as correlates of self-referral in Japan

BACKGROUND: Patients who frequently change physicians without letters of referral are common, and this has become a source of concern among primary care doctors in Japan. Previous studies have shown a correlation between psychiatric disorders and patient dissatisfaction and the utilization of medical resources. Abnormal illness behaviours such as hypochondria and inappropriate treatment seeking have been associated with various psychiatric disorders. The relationship between illness behaviour and self-referral in Japan has yet to be fully explored. OBJECTIVES: Our aim was to describe the characteristic illness behaviour and satisfaction level of self-referred patients in the general medicine clinic of Saga Medical School Hospital. METHODS: Using the Japanese version of the Illness Behaviour Questionnaire (J-IBQ), we examined the illness behaviour of 277 self-referred patients visiting the clinic. Patient satisfaction with previous medical care was examined with the use of our original Patient Satisfaction Questionnaire. The results were compared with those for physician-referred patients. RESULTS: Self-referred patients differed significantly from original-visit patients on the GH (general hypochondriasis), DC (disease conviction), AD (affect disturbance) and I (irritability) scales and from physician-referred patients on the GH and DC scales. In comparison with physician-referred patients, self-referred patients showed significant dissatisfaction with their most recent medical visit elsewhere. Dissatisfaction toward the medical staff, especially the doctors, was stronger than that toward the medical environment, waiting time or the on-site medical equipment. CONCLUSIONS: It is important to give patients appropriate overall support, not only physical but also emotional, when they first visit a general physician for medical advice. The J-IBQ may be a useful instrument for primary identification of self-referral patients with probable somatization syndromes. Open doctor-doctor and patient-doctor communication is necessary to increase patient satisfaction, which may be helpful to minimize the self-referral phenomenon in Japan.     

Patient satisfaction and the detection of psychiatric morbidity in general practice.

This study explores the relationship between the detection of psychiatric illness during general practice consultations and patient satisfaction. Psychiatric illness was defined as a score of greater than or equal to 3 on the 12-item General Health Questionnaire (GHQ-12). The hypothesis was that patient satisfaction would be higher after consultations during which psychiatric illness was correctly identified by the GP than after those during which it was 'missed'. Two hundred and twenty two patients attending seven doctors at one inner London practice participated. One hundred and ten patients (50%) scored greater than or equal to 3 on the GHQ-12. The GPs classified 76 of these 110 patients as having a psychiatric component to their illness and 34 as having an entirely physical illness. Only one significant difference in satisfaction was found between these two groups--patients in whom psychiatric illness was correctly identified reported more benefit from the consultation than patients in whom psychiatric illness was present but 'missed'. Possible explanations for the largely negative findings are discussed including the difficulties of measuring patient satisfaction and the distinction between detection and management of psychiatric illness in general practice.     

Can first-year medical students contribute to better care for patients with a chronic disease?

First-year medical students at the University of Western Australia are attached to a patient with a chronic illness in order to begin to understand the world of the chronically ill and their families. The patients are recruited by general practitioner preceptors who have been reticent in accepting first-year students because of their perceived immaturity and lack of medical knowledge. Not only have the preceptors' reservations proven groundless, but the teaching exercise has produced an unintended and positive side in that 35% of students discovered new information which was judged by the patients' general practitioners to be of significant help in the total management of patients' illness. Since these were only first-year medical students, the effect should be much greater with more mature students. Doctors often have incomplete records and act on incomplete information. Medical students are a means of correcting some of these deficits. In return they develop better psychosocial and communication skills and achieve considerable personal development by demonstrating to patients, their preceptors and themselves that they can be useful in contributing to more effective patient care.     

Indicators of the quality of general practice care of patients with chronic illness: a step towards the real involvement of patients in the assessment of the quality of care.

OBJECTIVE--To develop a list of indicators of the general practice care of people with chronic illnesses considered important by both patients and practitioners and to identify the indicators that are considered relevant for patient assessment of health care quality. DESIGN--Qualitative study with focus group interviews and a written consensus procedure. SETTING--General practice in the Netherlands in 1993. SUBJECTS--34 patients with chronic illness, mostly members of patient organisations, and 19 general practitioners with expertise in either chronic disease management or experience with patient surveys. MAIN MEASURES--Aspects of general practice care considered important for the delivery of good quality care that emerged from focus group interviews; the relevance of evaluations of 41 aspects of care for patients explored through the written consensus procedure. Those aspects of general practice care agreed to be both important and relevant by patients and general practitioners were considered to be suitable indicators for patient assessment of the quality of care. RESULTS--Patients and general practitioners differed to some extent in their assessment of the aspects of care that they considered important for quality. They agreed that most indicators of care that related to the ?doctor-patient relation? and to ?information and support? were relevant and therefore suitable as indicators for patient assessment of health care quality. There was less agreement about the relevance of indicators of ?medical and technical care,? ?availability and accessibility,? and ?organisation of services.? CONCLUSIONS--Several indicators of the quality of general practice care of patients with chronic illness were thought to be suitable for the patient assessment of healthcare quality, but other indicators were not, mainly because of reservations by general practitioners. IMPLICATIONS-- Qualitative methods can contribute to the selection of indicators for assessment of the quality of health care in areas where scientific evidence is limited or where patients' and providers' preferences are particularly important.     

‘Experts’, ‘partners’ and ‘fools’: Exploring agency in HIV treatment seeking among African migrants in London

In an attempt to promote patient agency and foster more egalitarian relationships between patients and doctors, discourse concerning health and wellbeing in the UK has increasingly centred around the notion of informed and ‘expert’ patients who are able to effectively input into the direction and management of their own health care and treatment. While the relationship between a patient and their doctor can play a vital role in influencing the treatment decisions and health-related outcomes of people living with long term illness, little is known about the ways in which people living with HIV actually perceive their relationship with their doctors, nor the implications this may have for the types of treatment they may seek to use and the related information that they share. Drawing on 11 focus group discussions and 20 repeat interviews undertaken in 2008–2009 with HIV-positive adult migrants from Zambia, Zimbabwe and South Africa living in the UK, this paper argues that patient-doctor relationships can be heavily influenced by the perceived legitimacy of different forms of medical knowledge and treatments and by culturally influenced ideas regarding health, wellbeing and agency. Despite a desire amongst some migrants to use ‘traditional’ medicines from southern Africa as well as other non-biomedical treatments and therapies, the research found that the perceived lack of legitimacy associated with these treatments in the UK rendered their use a largely clandestine activity. At the same time, many patients made clear distinctions concerning issues affecting their immediate health and factors influencing their more general wellbeing, which in turn, impacted upon the information that they chose to share with, or conceal from, their doctors. Such findings challenge assumptions underpinning policy promoting patient agency and have significant and, in cases, potentially adverse implications for the safety and effective administration and management of HIV treatments in African migrant populations and possibly more generally.     

Patient activism and the struggle for diagnosis: Gulf War illnesses and other medically unexplained physical symptoms in the US

We examine Gulf War illnesses--which include the fatigue, joint pain, dermatitis, headaches, memory loss, blurred vision, diarrhea, and other symptoms reported by Gulf War veterans--in relation to other medically unexplained physical symptoms such as multiple chemical sensitivity, chronic fatigue syndrome, and fibromyalgia. Our intent is to examine the diagnosis negotiations involved in these mysterious diseases, by showing the different forms of legitimacy involved in such interactions. Factors involved in diagnostic legitimacy are: diagnostic legitimacy in the medical community, lay acceptance of the diagnosis, uncertainty in looking for causes, and social mobilization. We conclude by noting that research may not be able to find any cause for these diseases/conditions; hence, it may be necessary to embrace medical uncertainty, and also to accept patient experience in order to facilitate diagnosis, treatment, and recovery process. Such a change can alter patients' expectations and taken-for-granted assumptions about medicine, and perhaps in turn reduce the frequency with which dissatisfied individuals form illness groups that mobilize to challenge what they see as an unresponsive medical system.     

Clinical exposure during clinical method attachments in general practice

BACKGROUND: There has been a significant decline in medical students' clinical experience in hospitals. Hospital-based teaching is struggling to provide medical students with sufficient experience of the common health problems of our industrialized ageing society. Hence, general practice has become an important locus for medical education. Published evidence, however, that students can access appropriate clinical experience in general practice is sparse. OBJECTIVE: To determine students' clinical exposure during clinical and method attachments based in general practice at two medical schools. EDUCATIONAL INITIATIVE: Students were attached to general practice tutors to learn clinical method in internal medicine. METHOD: General practice tutors from two medical schools collected data on age, gender, diagnoses, symptoms and signs of the patients they invited to teaching sessions. RESULTS: The frequency of diagnoses, symptoms and signs seen by medical students are recorded. Students mostly saw patients with chronic illnesses; the commonest diagnoses were ischaemic heart disease and angina. DISCUSSION: Our study has recorded the largest published database of clinical diagnoses, symptoms and signs encountered by students learning clinical method in general practice. It shows that students obtained a wealth of experience with patients with common chronic diseases. Students must also learn in the hospital setting, to experience the presentation of acute illness. The combination of teaching in these two settings is likely to provide the most effective technique to ensure that students encounter the common, acute and chronic conditions that affect patients in the 21st century.     

‘Rule your condition,don't let it rule you’: young adults’ sense of mastery in their accounts of growing up with a chronic illness

Poor control of chronic illness is often attributed to patients’ non‐adherence to medical advice and treatment. Policy and practice has traditionally focused on improving adherence, assuming that the more patients comply, the better their control and outcomes will be. Drawing on complexity theory, we question this logic in a secondary analysis of qualitative data from studies of young adults’ experiences of growing up with a chronic illness. Examining their sense of mastery of their condition, we found they valued both being in medical control of their condition and having autonomy but had different ideas about how to achieve these goals. While some young adults mostly shared the traditional medical view that achieving good control was the key to retaining their autonomy, others saw control and autonomy as independent, non‐linear and potentially conflicting goals. The latter endeavoured to achieve both goals by striking a balance, variously adopting strategies of engagement with and resistance to their regime in the changing social contexts of their lives. We suggest that policy and practice needs to do more to promote autonomy and adaptive capacity, rather than simply maximising adherence and control, recognising the mundane complexity of living with and managing a chronic illness.     

The Management of Secondary Gain and Loss in Medicolegal Settings: Strengths and Weaknesses

Individuals with chronic illness and disability are among the most difficult patients to treat. The health-care provider is faced with an array of physical, psychological, and social factors, requiring adoption of a biopsychosocial approach to treatment. This approach necessitates consideration of the benefits for the patient of remaining ill and disabled. These benefits have been termed the "secondary gains" of illness, and they may serve to perpetuate disability and illness behavior. This paper focuses on secondary gain and loss issues in patients with chronic, nonprogressive illness associated with chronic disability, who are evaluated and treated in medicolegal settings. In working with this population of patients, the health-care provider is faced not only with the usual secondary gains of illness (e.g., escape from family responsibilities), but must also deal with the myriad of secondary gain issues unique to medicolegal settings (e.g., seeking financial compensation). Consequently, identifying and managing secondary gain issues can be quite challenging. A model for managing these issues is presented here,following a more general discussion of secondary gain and related concepts. This model has proven very useful when incorporated into an effective rehabilitation program, such as the functional restoration approach to treating chronic musculoskeletal disorders. However, shortcomings of this model for managing secondary gain have become apparent. These shortcomings, and methods for overcoming them, are discussed. The overall purpose of this paper is to improve the health-care provider's ability to identify and manage both simple and complex secondary gain issues.     

Beyond community-based diabetes management and the COAG coordinated care trial

Objective: This article describes the patient management processes developed during the Council of Australian Governments (COAG) coordinated care trial and use of health outcome measures to monitor changes in utilisation patterns and patient well‐being over time for a subgroup of 398 patients with type 2 diabetes. Design: The Eyre component of the South Australian (SA) HealthPlus coordinated care trial was a matched geographically controlled study in which the outcomes for the intervention group of 1350 patients were compared with those of a similar control group of 500 patients in another rural health region in SA. Setting: The trial was carried out on Eyre Peninsula in SA across populations in rural communities and in the main centres of Whyalla, Port Lincoln and Ceduna. Care planning was organised through general practitioner practices and services negotiated with allied health services and hospitals to meet patient needs. Subjects: The SA HealthPlus trial included 1350 patients with chronic and complex illness. A subset of this group comprising 398 patients with type 2 diabetes is described in this report. Patients recruited into the three‐year trial were care planned using a patient centred care planning model through which patient goals were generated along with medical management goals developed by clinicians and primary health care professionals. Relevant health services were scheduled in line with best practice and care plans were reviewed each year. Patient service utilisation, progress towards achieving health related goals and patient health outcomes were recorded and assessed to determine improvements in health and well‐being along with the cost and profile of the services provided. Results: Significant numbers of patients experienced improved health outcomes as a consequence of their involvement in the trial, and utilisation data showed reductions in hospital and medical expenditure for some patients. These results suggest that methods applied in the SA HealthPlus coordinated care trial have led to improvements in health outcomes for patients with diabetes and other chronic illnesses. In addition, the processes associated with the COAG trial motivated significant organisational change in the Regional Health Service as well as providing an opportunity to study the health and well‐being outcomes resulting from a major community health intervention. Conclusions: The importance of the SA HealthPlus trial has been the demonstrated link between a formal research trial and significant developments in the larger health system with the trial not only leading to improvements in clinical outcomes for patients, but also acting as a catalyst for organisational reform. We now need to look beyond the illness focus of health outcome research to develop population based health approaches to improving overall community well‐being. What is already known: Much work has been completed in recent years tracing the clinical impact of more effective management of patients with chronic illness. Evidence suggests that more structured management of patient care and better access resources and support can improve patient well‐being and reduce demand on acute care services. What is needed, however, are mechanisms for managing patients to access relevant care and to comply with best practice protocols. Lowered HbA1c readings correlate with reduced crises for diabetic patients, but how can we encourage patients to engage in practices that actually lower these levels? What this study adds: The current study, based on work carried out during the COAG coordinated care trials, suggests that a structured patient centred care planning process can improve patient knowledge of their condition and increase motivation for sustainable behaviour change in the way they manage their illness. These processes of patient engagement and symptom monitoring have led to better long‐term health and well‐being for patients with diabetes. The wider application of such processes of care management will be an important next step in improving the management of health and well‐being at larger population levels.     

Screening anxious-depressive symptoms and pain in medical inpatients

AIM: Several studies indicate a relationship among depression, anxiety, pain and hospitalization. Depression has a bidirectional relationship with cardiovascular disease, and it is observed in HIV-positive individuals, in cancer patients and it often complicates chronic pain. METHODS: In order to assess dimensionally depressive and anxious symptoms and pain in medical inpatients, 327 non-psychiatric inpatients were assessed using the Hospital Anxiety and Depression Scale (HADS) and Visual Analogical Scale (for pain, VAS). Inpatients were hospitalized for neurovascular disease, chronic medical illness, cancer, infectious disease, cardiovascular illness, orthopaedic surgery and general surgery. RESULTS: Very high anxiety levels were discovered in cardiovascular, general surgery, infectious and neurovascular patients, whereas depression levels were higher among cardiovascular and chronic patients. The highest levels of pain were found among patients admitted to the Oncology Unit and those suffering from chronic medical illness. A stronger, direct relationship was obtained between anxiety and depression than between pain and anxiety or depression. No statistical differences were found in men and women. Statistically speaking significant differences were found in wards. Pain is a significant predictive variable for anxiety and depression (P<0.001). CONCLUSION: Screening for anxiety and depression should be included in the clinical interview carried out by the nurse at the moment of admission to the ward.     

Maintaining face in the presentation of depression: constraining the therapeutic potential of the consultation

This article discusses the concerns of patients diagnosed with depression to preserve 'face' in social and medical encounters. The findings are from a qualitative study of patient and GP accounts of the presentation, recognition and treatment of depression. Medical consultations are difficult encounters to accomplish successfully, especially for patients, who often strive to protect their privacy and personal integrity through the maintenance of face. Face work reveals the concern of participants to contribute to the success of the consultation as a social interaction. Patients' strategy of maintaining face helps to account for the commonly reported underdetection of psychosocial distress in general practice consultations. Many people do not regard the experience of psychosocial distress as an appropriate topic for medical consultation or scrutiny. In this case, face work can function as a means of maintaining privacy and resisting medical diagnosis and intervention. The concept of face has relevance in other areas of clinical care, including chronic and enduring pain, functional disorders, medically unexplained symptoms and even terminal illness. Consideration of face work reveals the extent to which the pressure to contribute to the success of the consultation as a social encounter may constrain participants' capacity to realize its therapeutic potential. The extent to which clinical interactions are governed by social etiquette also helps to explain the continuing inertia of the formal health care system and the difficulty of changing the ways that patients and doctors communicate with each other, and of increasing patients' involvement in medical consultations.     

Patient satisfaction with family physicians and general internists: is there a difference?

Although general internists and family physicians see similar types of patients, they have been found to have different styles of practice. It is not known whether these differences in practice style are associated with differences in outcomes of care such as patient satisfaction. This study examined whether patients of family physicians and general internists have different perceptions of the care they receive. National samples of recently trained family physicians and general internists were asked to complete questionnaires about their practices and to record information on all patient encounters during a three-day period. Three patients were randomly sampled from among those seen by each physician during the study period and were sent questionnaires that included questions about their satisfaction with the medical care they were receiving from the physician. Two hundred thirteen adult patients who saw 124 family physicians and 218 adult patients who saw 98 general internists participated in this study. Patients of general internists and of family physicians reported similar levels of satisfaction on all four dimensions measured (access, humaneness, quality, and general satisfaction) even after controlling for the effects of a variety of patient, practice, physician, and encounter characteristics. It is concluded that the fundamental differences in practice style that have been reported between family physicians and general internists do not seem to be associated with differences in patient satisfaction.     

Doctors and dirty work--the case of alcoholism

Abstract Doctors’treatment of certain classes of patient as dirty work is often ascribed to irrational reasons such as ignorance and prejudice. This is certainly true of the research tradition which seeks to explain why doctors avoid or dislike alcoholics. However, based on informal interviews with a group of Scottish general practitioners, I argue that, although all may be ignorant in some ways and a few are perhaps prejudiced, there are nevertheless other and quite rational grounds for their general avoidance of alcoholics. For alcoholics break three broad principles which shape conventional medical practice: the assumption of medical expertise, the belief that medical matters fall largely within the‘natural’sphere of things; and the assumption that, despite the doctors’inability to intervene or order, patients are normally motivated to comply with medical instructions. To break one principle would make matters difficult enough, to break all three renders normal consultations highly problematic. I conclude by noting that, although alcoholism has some unique features, the difficulties which its treatment entails are common to much of psychiatric practice also.