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Stories for Reprint
Chronic Disease Requires Thinking outside the Box, Physician Says
By Petya Stoeva, MARRTC Staff
Proper care for the chronically ill requires changes in the role of the physician and the patient, the places where it occurs and the overall nature of care, says Dr. Halsted Holman, rheumatologist and professor of medicine at Stanford University in Palo Alto, Calif.
Holman was the keynote speaker at the "Bridging the Quality Gap in Mid-America" health conference, which took place April 27-28 in Columbia, Mo.
People want better access to information about their diagnosis and its implications, treatments and consequences, Holman said, together with better coordination and continuity of their care.
So he suggested that the nature of care for the chronically ill should change by shifting the goal from cure to function and comfort, establishing management goals with the person and their family and providing care by a team, which includes the person with the disease. The person with the chronic illness should also start to take more responsibility for their own health and learn new ways to do that, Holman said, for example by better adherence to medication, more exercise and better emotional adjustment.
The role of the physician should also change, Holman said, and physicians should help people learn about their disease, share their authority with the patient and assure a continuous and integrated care. The places where people can get help can also change, Holman said, as home and community sites are often the best places to get such care, together with care by phone, home monitors or e-mail. The relationship between the physician and patient becomes a partnership at this stage, Holman said.
"Each brings complimentary knowledge and has reciprocal responsibilities," he said.
But physicians are unprepared to meet those expectations, Holman said, and quoted a 2001 survey of U.S. physicians, conducted by Johns Hopkins University School of Medicine and published in the medical journal Academic Medicine.
Results of that survey showed that, "the majority of practicing clinicians in both primary care and specialty fields felt their medical training had resulted in positive attitudes about their ability to care for persons with chronic conditions, but that they had received less training than they felt they needed in a range of specific chronic care competencies."
Such competencies were educating people with chronic conditions, providing end-of-life care, managing psychological and social aspects of chronic care, managing chronic pain, providing nutritional advice, and others. On a more optimistic note though, physicians who had graduated in the last 10 years reported fewer inadequacies of training than their colleagues who graduated more than 10 years ago.
Holman also gave California's health care system as an example of how rising costs of health care don't necessarily bring a better outcome.
For the past six years, Dr. Bridget McCandless, an internist of Independence, Mo, has been running a free clinic for uninsured adults with chronic diseases. Six months ago, she started applying a new approach to the care of her patients by creating a drop-in group medical appointment (DIGMA) for those with diabetes and wants to create another group for the people with asthma soon.
DIGMAs have been around for 10 years and were created by psychologist Edward Noffsinger while he was trying to manage his own illness.
In McCandless's DIGMA, people with diabetes meet her once a month as a group and discuss different topics, some of her choosing and some of theirs.
"We teach them techniques to manage the disease most effectively," she said.
This group medical appointment resembles a support group, but has two additional components - strong educational focus and direct medical care, McCandless said.
Although the group has been running for only half a year, McCandless is happy with the results.
"The patients feel like they're much more in control of the disease," she said. "It also has resulted in a number of uncontrolled diabetics seizing much better control. It also allows us to take care of more people in less time."
The practical side of such approach is also appealing, McCandless says, because she can see 10-12 people as a group in the time that would allow her to see only four people individually. The effective time management allows her to see these people every month instead of every three months, which is the standard practice for care of diabetes. Participants still have regular one-on-one visits with McCandless, but they are much briefer because most of the issues have already been resolved in the group meetings.
Privacy can be a concern for many but McCandless says while in the group meetings, people can share as much or as little as they wish and can be seen privately if they want to.
"Most patients don't seem to be bothered by the privacy issue," she said.
Holman also said in his speech that such an approach can be effective in solving the chronic care problem in the country.
"It focuses on the interaction of the patient, physician and other health professionals which is the heart of medical care," he said.
Moreover, the approach doesn't require new facilities or expensive technology, but only a change in the understanding and behaviors of those involved, Holman said.
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