Applying the principles of ebm

Exam Number: B132769Assignment Title: Applying the principles of Evidence- based Medicine.Justification of patient choice 5 marks 80/75 wordsIdentify a patient who has one or more chronic diseases for which there are important lifestyle considerations. Chronic diseases such as DM, HTN, COPD, PVD, CVD, HIV, Alcoholic having an impact on the patient and their modifiable risk such as diet, exercise and weight loss. Habits which are detrimental to health such as smoking and alcohol and overweight. R.K. is an obese 50-year-old, male, non-compliant diabetic, hypertensive, alcoholic who sustained injuries to his left hallux. His homemade treatments resulted in a gangrenous infection and a recent amputation. I have chosen R.K. for my discussion since he is representative of many patients seen in my local health-centre and have similar non-communicable diseases, nurse amputations due to poor self-care, non-compliance to medication, rely solely on homemade remedies and poor lifestyles that are detrimental but modifiable through diet, exercise and weight-loss.Case description 15marks (3x5marks) 225/225 words R.K. presented with a cellulitic, edematous left-limb and a malodorous, pus-stained bandage. B.P: -170/96mm/Hg, RBS-350mg/dl and Urine analysis:2+ketones. He resides with his wife and daughter in a village home with occasional amenities. He is a taxi-driver, of low-socioeconomic-status, the sole income-earner and unemployed due to his injury. R.K. expressed that his wound worsened due to unhygienic bandage reuse and was concerned that he needed a further amputation. He expected a prescription for antibiotics and needed reassurance on his limb. R.K. self-care involves herbal remedies; cultural-traditional therapies and spiritual-healers advice. He was non-compliant with clinic visits due to busy working hours. His consultation triggers were due to his wife’s persistence, no improvement in wound healing after a month and the need to resume working. He feared for further loss of his limb and the treatment cost if his condition deteriorated. He lamented that his current condition affected his pub visits and socializing. R.K. has a strong external-locus of control, he believed that although his co-morbidities were hereditary it was inevitable. His fear of diabetic and hypertensive medications arose from his mother who he believed developed renal failure from them. He had poor perception of severity and susceptibility to his weight, uncontrolled hypertension, hyperglycemia and alcohol consumption.2 Although he has low self-efficacy, his cues-to-action was his fear of limb-loss and being unable to provide for his family.2Risk Explanation 10 marks 166/150 wordsDescribe your actions in explaining risk and helping the patient to modify their behaviorFollowing the Calgary-Cambridge framework, I established a rapport with R.K., determined his capacity and addressed his fears, concerns and misinformation.5,13 I listed all his risk factors on paper using simple words, short sentences in bulletin format, layman’s terms, avoided medical jargon, used small picture drawings and flowcharts to link his risk to his medical conditions.10 I used pamphlets provided to aid in explanation, decision aids and paling palettes in showing the efficacy of diabetic and anti-hypertensive medication.4,8,7,11 I incorporated R.K. cultural beliefs and the use of traditional therapies into the consultation. Throughout the interaction I was empathic, spoke slowly, checked his understanding of what was explained, reclarified and re-summarized the information and paid attention to his body language, verbal and non-verbal cues. Using shared-decision making and his cue-to-action, I encouraged R.K. to set a goal and decide how he can adapt changes into his lifestyle to achieve it. I praised him on setting one and encouraged him to attend a follow-up visit to check his progress.Reasons for patient’s beliefs 10 marks 150/150wordsCritically analyse the possible reasons behind the patient’s beliefs about their symptoms and their risk, with reference to the literature.A qualitative interview study of 8 focus groups at a Jordan health-center was done on 38participants from July-Dec2016.15 It analyzed the attitude, knowledge and perceptions of patients regarding Type2Diabetes. This study was chosen since participants were similar in culture and ethnicity to my setting. A majority had a strong-external locus of control such as fatalistic beliefs and diabetes being an inevitable condition in those who had a positive family history. Many, lacked awareness, had poor knowledge and ignorance to diabetes being long-term and incurable. Some had a false belief that psychological shock and stress lead to a ‘sudden’ onset of diabetes. Mis-information lead to fear of painful medication injections, side-effects and patients took them only when symptomatic. Some believed that the onset age of diabetes and type of treatment were perceived as indicators of its severity and diabetes is a “sugar” disease and staying away from only sugar would help. Role of the family physician in modifying risk, risk perception and lifestyle 30 marks 440/450wordsCritically analyse the role of the family doctor in modifying illness-behaviours, risk perception and lifestyleIn order to modify a patient’s illness behavior, a family physician needs to have effective communication and build a strong doctor-patient relationship. The role of the family physician is to help identify what are the patient’s attitude and health beliefs towards their illness and discover what are their biological, psychological and environmental barriers to make changes.6 Once a patient cue-to-action is determined, the family physician, through the motivational technique interviewing, can empower and promote a patient’s self-efficacy. The role of the family physician is to help a patient embrace a lifestyle change through support, tailored advice, setting realistic, obtainable goals and self-monitoring. Several theoretical models have explored interventions in helping patients embrace lifestyle changes. By providing social-cognitive learning, family physicians can encourage patients through praise, positive reinforcements and affirmation, or reassurance when they may have faltered from their goals.16 With psychosocial interventions family physicians can help enhance a patient coping skills with an illness and through psychoeducational intervention incorporate supportive family members and friends by increasing their understanding and management of the illness.17In order to modify patient’s risk perception, the role of a family physician is to explore a patient’s exaggerated fears of the use of medication, treatment, stigma, dread, misconception and to correct any inadequate or incorrect information. Family physicians can help lessen patient’s opinion of danger by providing them with information that is understandable and unambiguous.22 Through appropriate decision aids patients can be better equipped to make informed decisions on their health, increase their involvement in decisions and have more accurate perception of risk.4,11,23 Limitation arise where patient finds it too difficult to make changes and rely on the wait and see approach. Some patients, although well informed, may evaluate risks by using heuristics and other informal thought processes and unrealistic optimism by a tendency to believe that risks pose a less serious threat to oneself than they do to others.25The use of motivational interviewing technique (M.I.T) and the transtheoretical model of change can aid a patient in modifying their lifestyle by helping them evaluate their health status and determine whether any changes are needed. Once a patient has established motivation to change, the role of the physician is to work alongside the patient, address concerns, and help them towards their goals. M.I.T helps increase a patient’s autonomy and therefore help them to maintain long-term lifestyle change and new, healthier behaviors. 3,26However, a limitation is that some patients resolve to continue with unhealthy lifestyle choices despite the knowledge about their illness given to them. Some patient might relapse to earlier stages in the transtheoretical model and view it as a failure and give up completely.26Incorporation of Evidence-Based-Medicine, risk assessment and risk communication 20 marks 308/300wordsCritically analyse the ways in which EBM, risk assessment and communication can be incorporated into the consultation, with reference to at least one theoretical model of the consultation. (Calgary/Cambridge)Evidence-based medicine, risk assessment and risk communication can be incorporated into the Calgary-Cambridge theoretical model6. The model promotes effective communication by establishing a strong doctor-patient relationship and person-centered care through advising open-ended questions, being mindful of verbal and non-verbal cues, active listening and eye contact. It explores patients’ ideas, concerns, expectations and help determine their health beliefs and locus of control. Through effective communication and active listening, lifestyle risk factors can be identified and assessed. Although evidence-based medicine has set rules and guidelines to follow it can be tailored to the patient and the availability of resources. The information on health risk and disease can be related to the patient in small chunks, layman’s terms and in non-medical jargon. Treatment success, options and lifestyle change can be explained to patients through decision aids, written, flowcharts, diagrams, videos or models.23 The Calgary-Cambridge model promotes shared decision making, therefore risk communication can be better complied to since patients are encouraged to make inputs into appropriate individualized decisions about reducing their risk. Unfortunately, one patient may present with multimorbidity and evidence-based medicine are generally focused on a single disease.16 Due to time-restricted consultation it is difficult to evaluate each disease in one consultation without overwhelming the patient. Lamentably, limitations arise where patients are loss to follow-up due to overbooked clinics, prolong waiting time and getting time off from work. Accessing information on evidence-based medicine and treatment trials require costly subscriptions and the medication being used in the latest trials maybe unavailable. Some patients cannot embrace the lifestyle change since access to healthy foods maybe be costly and busy work-life prevents them from exercising. These factors may cause us to disregard the Calgary-Cambridge model and overwhelm patients with information so that if patients are loss to follow-up, we would have equipped them with all the information needed to make the right decisions.Reflection 10 marks 164/150 wordsOur healthcare is over-burdened with patients of multimorbidity, low socioeconomic backgrounds and strong cultural beliefs and reliance on traditional remedies. We endeavor to view the illness from the patient’s perspective and incorporate their cultural values. Physicians currently incorporate decision aids, media, videos and drawings to better inform patients of evidence-based-medicine about their diseases. We are trying to gravitate away from the paternalistic approach to consultation and build a strong doctor-patient relationship to treat the patient and not just the disease. Shared decision making and the use of the motivational interviewing technique is not routinely practiced due to time constraints and the time-consuming process of a successful outcome. Additionally, patient’s perception of severity, susceptibility, and their attitude to their risk factors are never fully evaluated. Perhaps a Calgary-Cambridge model rubric can be provided and incorporated into consultations to aid in effective communication. If it is embraced, then we can help modify patient’s illness behavior and empower them to set healthy long-term goals and maintain them. Word count 1547+17 1564Word limit 1500References:1. Allmark, P and A Tod. “How should public health professionals engage with lay epidemiology?” Journal of medical ethics vol. 32,8 (2006): 460-3.2. (2019). Health Belief Model. 3. Hall, K., I Lubman, D. and Gibbie, T. (2019). RACGP – Motivational interviewing techniques – facilitating behaviour change in the general practice setting. 4. Paling John. Strategies to help patients understand risks BMJ 2003; 327 :7455. Calgary Cambridge guide to the medical interview – communication process. [online]6. Institute of Medicine (US) Committee on Health and Behavior: Research, Practice, and Policy. Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences. Washington (DC): National Academies Press (US); 2001. 5, Individuals and Families: Models and Interventions. 7. Raingruber, B. (2019). Health Education/Health Promotion. [online] 8. Brokensha, Glyn. (1998). Strategies to assist patient compliance with lifestyle changes. Australian Prescriber. 9. Paek, H., & Hove, T. (2017, March 29). Risk Perceptions and Risk Characteristics. Oxford Research Encyclopedia of Communication. Ed. 10. “Lifestyle-related Health Behavior Change the Nurses Role.”” 11 2018. All Answers Ltd11. “FROM DRUG AND THERAPEUTICS BULLETIN: An Introduction to Patient Decision Aids.” BMJ: British Medical Journal

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