The clinical encounter as local moral world: Shifts of assumptions and transformation in relational context

In this study we consider the process of the clinical encounter, and present exemplars of how assumptions of both clinicians and their patients can shift or transform in the course of a diagnostic interview. We examine the process as it is recalled, and further elaborated, in post-diagnostic interviews as part of a collaborative inquiry during reflections with clinicians and patients in the northeastern United States. Rather than treating assumptions by patients and providers as a fixed attribute of an individual, we treat them as occurring between people within a particular social context, the diagnostic interview. We explore the diagnostic interview as a landscape in which assumptions occur (and can shift), navigate the features of this landscape, and suggest that our examination can best be achieved by the systematic comparison of views of the multiple actors in an experience-near manner. We describe what might be gained by this shift in assumptions and how it can make visible what is at stake for clinician and patient in their local moral worlds—for patients, acknowledgment of social suffering, for clinicians how assumptions are a barrier to engagement with minority patients. It is crucial for clinicians to develop this capacity for reflection when navigating the interactions with patients from different cultures, to recognize and transform assumptions, to notice ‘surprises’, and to elicit what really matters to patients in their care.     

An observational study assessing the pathways to care among treatment seeking users of natural opiates

Abstract

Background: Natural opiate users constitute a large proportion of opioid dependent individuals in India, and enjoy socio-cultural sanction in certain parts of the country. However, no study has assessed the pathways to care among this population in India.

Objective: To assess the pathways to care among treatment-seeking natural opiate dependent individuals.

Method: This cross sectional, explorative study was conducted at a tertiary care drug treatment centre located in North India. A total of 125 male participants aged >18?years, seeking treatment for natural opiate dependence from our outpatient clinic were included. A semi-structured proforma and WHO mental health encounter form was applied to assess socio-demographic, treatment details and pathways to care.

Results: The mean age was 46.17 (±11.98) years. Poppy husk (phukki/doda/posht) was the most common primary natural opiate used (84%). First point of treatment contact was addiction psychiatrist (n?=?90; 72%) in majority. First time treatment seeking was either by self-referral (60.8%) or referral by relatives and friends (24.8%) with mean time lag of 18.63?years after the onset.

Conclusion: Natural opiates dependent patients seek treatment late in the course of their illness, often directly from a tertiary addiction treatment centre. Barriers to seek treatment needs to be addressed.     

A classification model of patient engagement methods and assessment of their feasibility in real-world settings

Objective

Examine existing reviews of patient engagement methods to propose a model where the focus is on engaging patients in clinical workflows, and to assess the feasibility of advocated patient engagement methods.

Methods

A literature search of reviews of patient engagement methods was conducted. Included reviews were peer-reviewed, written in English, and focused on methods that targeted patients or patient–provider dyads. Methods were categorized to propose a conceptual model. The feasibility of methods was assessed using an adapted rating system.

Results

We observed that we could categorize patient engagement methods based on information provision, patient activation, and patient–provider collaboration. Methods could be divided by high and low feasibility, predicated on the extent of extra work required by the patient or clinical system. Methods that have good fit with existing workflows and that require proportional amounts of work by patients are likely to be the most feasible.

Conclusion

Implementation of patient engagement methods is likely to depend on finding a “sweet-spot” where demands required by patients generate improved knowledge and motivate active participation.

Practice implications

Attention should be given to those interventions and methods that advocate feasibility with patients, providers, and organizational workflows.     

Encounters between adolescents and general practice in Australia

Aim: To describe the nature of the encounters between adolescents and general practice in Australia. Methods: Data collected by the Bettering the Evaluation and Care of Health programme from 1998–2004 were analysed. Data for 10–14‐year‐old and 15–19‐year‐old males and females were compared with data for 25–29‐year‐olds. The outcome measures included: number of encounters compared with other age groups, reasons for encounter, problems managed, treatments prescribed and referrals made for key problems and types of consultations. Results: Adolescents have the lowest rate of encounter with general practice, compared with all other age groups. Respiratory, skin, musculoskeletal and unspecified (fever, injury, weakness) problems accounted for the great majority of reasons for encounter and problems managed. Management of mental health problems, preventive health care and health education were very infrequently managed problems. Standard surgery consultations were more common among adolescents than among young adults. Conclusions: Adolescents have a relatively low rate of encounter with general practice and the problems managed are primarily physical ailments. There is great scope to improve delivery of preventive health care and to increase management of mental health problems.     

GENESYS--a generating system for the CASE natural language model

A library of computer-aided simulations of the clinical encounter, CASE, is being developed using GENESYS, a semi-automatic generating system. There are three essential phases involved: 1. the interrogation phase, 2. the generation phase and 3. the integration phase. A Coursewriter III program exists called MREC (medical record entry course) which interrogates the author at a terminal, gathering information which is subsequently processed by a series of PL1 programs to form a CASE. This paper describes the logic of this three-phase process.     

Landscape, care and the relational self: therapeutic encounters in rural England

Over the last decade a number of studies have employed notions of therapeutic landscape to describe the ways in which places become implicated in processes of healing or health enhancement. While this work has usefully highlighted the environmental, social and symbolic dimensions of such places, relatively less consideration has been given to the relational dynamics through which these therapeutic effects emerge. In this paper I seek to address this absence through engagement with two related bodies of work: ecological formulations of place and relational notions of selfhood. These ideas are explored with reference to the experiences of guests at a respite care centre in Dorset, a predominantly rural county in southern England. Alongside its residential services, this centre places a strong emphasis on facilitating guests' engagement with the wider natural environment in which it is set. A number of general analytical and methodological points are developed with regard to future therapeutic landscape research.     

The progression of suffering implies alleviated suffering

There is a lack of research focusing directly on both patients' suffering and alleviated suffering in relation to care. The aim of this paper was to investigate the progression of suffering in relation to the encounter between the suffering person and the caregiver from the perspective of an understanding of life. The progression of suffering is assumed to be an existential 'sign' of the development of understanding of life as an ontological or spiritual entity, which demands a meaning-creating encounter between the patient and caregiver. The concept 'existential caring encounter' was used to describe how the encounter between patient and caregiver can create meaning in communion and thereby alleviate suffering by making it bearable. The study was carried out using an interpretive, hermeneutic approach. The study as a whole comprises three parts, and these include letter-writing and interviews. The findings are described by the following main theses: (a) a darkness in life understanding is existentially experienced as unbearable suffering and requires an encounter involving attentive care and confrontation; (b) the turning point means that the struggle of suffering begins; and (c) the encounter involves being meaning-creating in a communion in the struggle of suffering. An understanding of the patterns of unbearable and bearable suffering can be of help to the caregiver in caring for the patient by serving as a basis for meaning-creation in communion. This may thereby be a way of alleviating the patient's suffering by making it bearable during the progression of suffering.     

Releasing and relieving encounters: experiences of pregnancy and childbirth

The experience of childbirth is an important life event for women, memories of which may follow them throughout life. The aim of the study reported here was to synthesize the results from four selected studies describing these experiences by focusing on women's and midwives' experiences of the encounter during childbirth, as well as experiences of pregnancy from the women's perspective. The setting was the Alternative Birth Care Centre (Sahlgrenska University Hospital, Goteborg) and Karolinska Hospital (Stockholm, Sweden). A qualitative method grounded in phenomenology and hermeneutics was used as a basis for the studies and synthesis. The essential structure may be conceptualized under the heading 'releasing and relieving encounters', which, for the woman, constitutes an encounter with herself as well as with the midwife, and includes stillness as well as change. Stillness is expressed as presence and being one's body. Change is expressed as transition to the unknown and to motherhood. In the releasing and relieving encounter, for the midwife stillness and change equals being both anchored and a companion. To be a companion is to be an available person who listens to and follows the woman through the process of childbirth. To be anchored is to be the person who respects the limits of the woman's ability as well as her own professional limits in the transition process. A releasing and relieving encounter implies a sharing of responsibility and participation for women. This may be understood as a unique feature, which differs from other caring encounters and should be further studied.     

改善门诊流程 促进医患和谐

改善门诊流程就是以病人为中心，在现有就诊流程的基础上，充分利用信息技术手段，对门诊的作业流程进行重新思考和重新设计，以求得医院门诊在成本、质量、服务和速度等方面获得进一步的改善，从而减缓医护人员与病人之间可能出现的矛盾。从几个方面探讨了改善门诊流程的途径和方法，经多家医院实施和验证，在医护人员工作效率、病人满意度、医院效益等指标上都有了显著提高，和谐的医患关系得到加强。