Chronicity, character and context in type 2 diabetes care

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					Chronicity, character and context in
  type 2 diabetes care in general
 Implications for health inequities

                            Dr. John Furler11
                             Dr. John Furler
                         Professor Doris Young11
                         Professor Doris Young
                          Dr Marilys Guilemin22
                          Dr Marilys Guilemin

                 1 Dept of General Practice, University of Melbourne
                 1 Dept of General Practice, University of Melbourne
              2 Centre for Health and Society, University of Melbourne
              2 Centre for Health and Society, University of Melbourne

    Study supported by an RACGP CVD Research Grant, Travel Fellowship and
    Study supported by an RACGP CVD Research Grant, Travel Fellowship and
                             NHMRC Scholarship
                             NHMRC Scholarship
   Health inequity and medical care?
• A practicing GP with an interest in health
   – How might we best understand the
     relationship between the micro, day-to-day
     work of general practice and the existence of
     social inequalities in health and health care?
• To study health inequity in a social and relational
  sense and the role of medical care within that.
      Diabetes as a case study
• Diabetes: a case study of how GPs and patients engage
  with social and economic adversity
   – Common: multiple complex tasks for GP and patient:, the
     “archetypal chronic disease” (Martin):
   – Chronic: case study of the way chronicity shaping GP work
   – Pervasive: Self management paradigm, focus on lifestyle and
   – Health inequities: Prevalence and mortality is 2-3 x more
     common in socioeconomcally disadvantaged communities in
• Intensive medical care influences control and
  outcomes, but what about usual care?
• “Quotidian”: Mundane, ordinary, day to day practice
   Patient centredness and health
• “Patient Centredness”: an idealised model of medical care
  with a focus on psychosocial context.
   –   A “biopsychosocial” perspective
   –   Awareness of “patient-as-person”
   –   Orientation to sharing power and responsibility
   –   Development of a therapeutic alliance
   –   Awareness of “doctor-as-person”
                                                  (Mead and Bower, 2000)

• Contains an implicit promise….
   – If inequity is at heart a social and relational issue then a
     social and relational model of practice is a logical response.
• What happens to patient centredness in practice?
• Qualitative interview study
• Face to face interviews with 18 patients with type 2
  diabetes and 16 GPs (not dyads)
   – Purposive and theoretical sampling
   – Metropolitan and regional Victoria, Australia
• Data
   –   Perceptions and understandings of SES and social class
   –   actual clinical stories and illness narratives
   –   ideal types
• Analysis
   –   Thematic, ‘grounded hermeneutic’ approach
   –   Social constructionist theoretical framework
  The social in patient centredness
• A focus on social context suffuses models
  of patient centredness
  – Understanding disease and illness
     • The voice of the lifeworld of the patients particular
       social context and how this gives meaning to illness
  – Understanding the whole person involves a
    consideration of social context
     • As a source of prediction or explanation
     • As a resource in helping patients arrive at meaning
• A lack of conceptual clarity
    Engaging with the social world
• SES: Uncertain and unreliable
• Social class
   – non-existent?
      • PT: No I don't, well is there such a thing as a class
        system in Australia?
   – Internal, attitude dependent
      • GP: I suppose class is a sort of a, it is a perceptual thing isn't
        it I think to some extent.
• Social position, character and health
      • GP…someone who is a bit more laid back about economic
        wealth would be more laid back and carefree (about their
        health) and might say, "What happens happens." […] you
        only live once and who cares […] some people that don't
        care, they think it (diabetes testing and treatment) is bullshit
        or they don't they don't want to even know about it
    The social in biopsychosocial:
        ‘Unspoken practice’
• Minimise formal socio-demographic enquiry
   – But active social assessment and grouping continues
• Favour informal, implicit, unspoken enquiry:
   – “Clocking and chatting”
      • GP: So again you are checking off or clocking off all the
        non-verbal cues
      • GP: you pick it up from getting to know them over a time
        and just chatting uhh... You get a feel for their attitudes
   – Language literacy and congruence are key
      • GP: its like talking two languages..I say scientific and they
        go "Uhh..?“
   Engaging with the social world
• GPs and patients together “bury” the social and
  focus on the individual
   – GP and patient both active in this
      • GP: so it is more than just your social and your
        economic, it is you. Where do you fit in? Who are
        you? Where are you in this world of your own?

      • PT: I accept people for face value for who they are
        regardless of whether they are doctors, MPs or
        whoever they are just, garbos, they are people so it
        shouldn't have anything to do with […]their health
        care at all
Sharing power & decision making
•   The central ‘linchpin’ of patient centredness
•   Three overlapping but not identical concepts
    – “Finding common Ground”
        • Mutual understanding and agreement in defining the
          problem; establishing the goals ;identifying the roles
    – Sharing power and responsibility
        • Sociopolitical dimension
    – Shared Decision Making
        • Between paternalism and consumerism
• Again, a lack of conceptual clarity
• How is decision making played out in practice?
Conflating social disadvantage and
        clinical difficulties
• Implicit social positioning and perceived social
  disadvantage anticipates clinical difficulties
      • GP: Okay now this by definition means I am going to
       be choosing a fairly challenging patient for myself …

      • GP:…so this patient would be more challenging and
       more difficult...sometime frustrating.

      • GP:…it affects perhaps what I think they may have
       experienced […] if I ask them to do something how
       likely is it to get done
  Sharing power & decision making
• The context of chronicity: Competing agendas
  – Efficiency and accountability
     • Adhering to CPGs, Quality indicators, targets, etc
  – Devolving self management
• A resulting tension
     • GP: … it's a little frustrating because you
       think…We discussed that weeks ago and its just
       reappeared and you God , your repeating
       stuff […] I get the vibes back from him as if to say
       “well your only a young bastard I mean what would
       you know…it’s tough”…(and) I'm thinking ...well
       if your diet was better controlled…
   Decision making in diabetes care
• Control (of disease and personal) is idealised,
  autonomy and compliance run together
      • GP: Then to empower patients to look after their
       health better...if someone weighs 120 kg and they
       don't want to lose weight I’ll say fine this is what
       might happen to you, this is what happens to people
       that weigh that, but I'm not going to push it I've
       talked to you 57 times already about it. Its your
 Decision making in diabetes care
• Clinical guidelines used as a strategy for
  disengaging with patients
  – I haven't given up on her..I still try to encourage
    her… with some people I do give up if they're
    persistently not interested, I'll spend less energy on
    them ..I'll do all the requisite tests, you know they'll
    have their HbA1cs and I'll weigh them and so forth
    and check the feet…
Shared decision making as an outcome
  • A looping phenomenon
     – Social positioning is linked to…
     – Ascribed capacity & autonomy leading to…
     – Differing expectations for patients which leads the GP to…
     – Engagement with some patients around science, language and
       information which in itself prompts...
     – Feedback from patients which tends to…
     – Reinforce social positioning…
  • Result
     – Shared decision making may be deployed as a marker of
     – Guidelines may be used as a way of disengaging
 Conclusion: Revisiting patient
• Lack of clarity and conflict over the role of
  social context in practice
   – Unspoken social positioning
• Social positioning problematises individuals
   – Shared decision making as a marker of “fit”
     rather than a strategy of empowerment
• Distinct relationship trajectories bearing the
  imprint of social structure
• Paradoxical recentering of the doctor
   – Self aware, reflexive practice
 Revisiting patient centredness and
         health inequalities
• Three new dimensions of patient centredness.
  The extent to which care
  – Legitimates the social
     • Acknowledging the limits and context that both GP
       and patient work within.
  – Destabilises notions of compliance and
     • Eg Entering the patients context of strategic non
  – Challenging ideas of congruence
     • Curiosity and cultivation of a new shared beginning