Fastly
The SBS Toolbox:
Clinical Pearls from the Social and Behavioral Sciences
Saba GS, Satterfield J, Salazar R, Adler S, Hauer KE, Chen HC, Hughes D, Azzam A, & Shore W.
Corresponding Author: George W. Saba, PhD (GSaba@fcm.ucsf.edu)
The authors acknowledge contributing authors Shane Snowdon, Maria Wamsley, MD, Joyce Chu, PhD, administrative assistant Anne Sajdera, and student reviewers Akpene Gbegnon, Courtney Gonzales, Jasmine Lai and Brynn Utley.
Table of Contents
SOCIAL AND BEHAVIORAL SCIENCE PEARLS TOOLBOX
INSTRUCTOR’S GUIDE
WHAT IS THE SOCIAL AND BEHAVIORAL SCIENCE PEARLS TOOLBOX?
The Social and Behavioral Sciences (SBS) Pearls Toolbox is a curricular resource from the SBS Curriculum Committee of the School of Medicine, University of California, San Francisco (UCSF). The Toolbox consists of brief summaries of key topics in SBS teaching frequently covered during the first two years of medical school training. It can serve as a summary of SBS content taught during the preclerkship years and a guide for translating it into the clerkship experience.
WHAT ARE CLINICAL PEARLS INCLUDED IN THE SBS TOOLBOX?
The following files are included in this resource:
Instructor’s Guide ii
Adherence: Skills for the Clinician – G. Saba, PhD & J. Satterfield, PhD 1
Behavior Change: Skills for the Patient – G. Saba, PhD & J. Satterfield, PhD 3
Behavior Change: Skills for the Clinician – G. Saba, PhD & J. Satterfield, PhD 5
Biopsychosocial Model – J. Satterfield, PhD & J. Chu, PhD 8
Chronic Care Model – M. Wamsley, MD 10
Chronic Pain – K. E. Hauer, MD & J. Satterfield, PhD 12
Complementary & Alternative Medicine – S. Adler, PhD 13
Depression – G. Saba, PhD 15
Discharge Planning - D. Hughes, DrPH 17
Explanatory Model of Illness – J. Satterfield, PhD 19
Health Care Disparities & Provider Bias – R. Salazar, MD 21
Health Literacy – R. Salazar, MD 22
Intimate Partner Violence – Merik Gross, MD 24
Language – R. Salazar, MD 26
LGBT Issues in Healthcare – S. Snowdon & R. Salazar, MD 28
Maximizing Care in Varied Health Care Systems – D. Hughes, DrPH 30
Medical Errors – D. Hughes, DrPh 31
Social Support – J. Satterfield, PhD 33
Socioeconomic Status – R. Salazar, MD 34
Stress & Coping – J. Satterfield, PhD 35
WHAT IS THE PURPOSE/GOAL OF THE PEARLS TOOLBOX?
As medical students transition from the classroom to the clerkships, they must translate knowledge to clinical skills for patient care. They face the difficult challenge of integrating a curriculum that has spanned the various domains of medicine, often including the Social and Behavioral Sciences. Given its relevance to most aspects of medicine, the SBS curriculum may occur throughout the preclerkship years in various parts of the curriculum, or it may be consolidated into a single class. The topics generally include a wide variety of conceptual and clinical aspects of SBS (such as health risk behaviors, behavioral modification strategies, stress, coping) and are often introduced through multiple lectures, seminars, independent learning modules, and case discussions.
Either as a primary, introductory teaching tool or to aid students’ recall of important SBS information and guide their application of it during their clerkship experience, we have developed a toolbox of “SBS Clinical Pearls.” SBS faculty, Clerkship Directors and medicals students reviewed the SBS curriculum and identified the key SBS concepts that students will find most useful throughout all clerkships. These “Pearls” can serve as short summaries to remind students of what to focus on in clinical encounters. They can inform clerkship directors, faculty preceptors and housestaff of what students may have learned prior to the third year or could learn as MS3s. Clerkship faculty can further use the “Pearls” to highlight relevant SBS issues during case discussions, clinical precepting and videotape review of patient visits.
Educational Objectives
• To serve as a primary teaching tool of core SBS concepts relevant to clinical care
• Or, to assist students and faculty in consolidating previous learning in the Social and Behavioral Sciences from the preclerkship years
• To facilitate the application of this SBS content to the clinical care of patients and families during the clerkship experiences
WHO SHOULD USE THE SBS PEARLS TOOLBOX?
Faculty: During patient presentations, clerkship seminars, and planning for patient care, faculty can use these pearls to highlight the appropriate social and behavioral issues. The Pearls toolbox can inform clerkship faculty of what SBS content each student may have been exposed to during their first two years of training.
Housestaff: Students often learn what is most valued in clinical care by observing and learning from their senior residents. Housestaff can use the pearls to help orient students to what information should be gathered during patient interviews, to what should be included in a patient presentation, to identify teaching points during patient care discussions, and to provide guidance in planning and discharge.
Students: When caring for patients in the outpatient or inpatient setting, students can refer to the SBS pearls toolbox to identify relevant issues to address in their present or future care. The toolbox can serve as a reminder of what they may have learned and suggest practical examples of how to apply it to their patients.
DOES THE PEARLS TOOLBOX FOLLOW A PARTICULAR ORDER?
The SBS Toolbox consists of 20 pearls that are written to stand on their own when the topics they address emerge in clinically relevant teaching situations during the clerkships. They do not need to be used in any particular order, and one can use any or all of the summaries. They can be used at any time during the clerkship year and introduced in any clerkship. Each of the pearls includes definitions and/or key concepts; clinical examples and suggested guidelines; and references or resources for further study.
HOW WERE THE PEARLS TOOLBOX DEVELOPED?
As the UCSF SBS faculty began to focus on developing SBS curricula for the clerkship year, the need emerged to find a practical tool for students that would help them apply what they have learned in the classroom to their patient care. Faculty experiences in some clerkships, such as Neurology and Psychiatry, suggested that a compilation of brief guidelines would assist students and faculty in attending to the important SBS issues that are appropriate for a given patient case. This led to the idea of creating the compilation of various, one-page clinical pearls that could be used across the clerkships.
A list of the key topics that would be appropriate across clerkships was developed through multiple discussions with SBS faculty, Clerkship Directors and medical students. The list was not intended to be exhaustive; however the goal was to develop a manageable resource. Groups of faculty experts drafted the one-page pearls. Four students (Class of 2009) were recruited to review and revise the pearls.
In the 2008-2009 academic year, a number of the pearls have been used in two UCSF clerkship experiences: the patient case seminar sessions of the Neurology/Psychiatry clerkship and in the Family Medicine Seminar of the Parnassus Integrated Student Clinical Experiences (PISCES) clerkship. The Pearls Toolbox has been also used during the Foundations of Patient Care curriculum during the second year of medical school to reinforce SBS learning during 2008.
HOW MIGHT THE PEARLS TOOLBOX BE IMPLEMENTED?
Clerkship directors could distribute the pearls to their faculty preceptors and residents to be used in patient consultations and in seminar discussions. Students could also be introduced to the pearls prior to their clerkship year. For example, we have introduced it to UCSF students during their Transition to Clerkship curriculum just prior to the start of their third year. It has also been posted on the UCSF digital curricular website to be available to students and faculty. We plan to revisit the use of the toolbox during the middle of the clerkship experience in small group settings during their Intersession curriculum. The Intersession curriculum brings the entire class together to reflect on their clerkships experiences three times during the third year. This setting would allow students to discuss how they have used the toolbox on various clerkships up until that time.
Each clerkship or even clerkship site may have its own particular needs and uses for the SBS Toolbox. We encourage adaptation of these materials to best suit your program and your learners.
Prior to implementation, users need to identify if and where the content covered in the specific clinical pearl has been taught in the preclerkship years. This will help inform the user and the other participants about what the student needs to learn or has already learned and how the clinical pearl can serve as a reminder and a guide to the clinical needs of the patients and families in the current clerkship.
We list several examples of how the Pearls might be used in the typical course of inpatient or outpatient clinical practice, teaching, and supervision.
• Didactic Seminars and Discussion Groups
A number of clerkships host regular didactic seminars and/or discussion groups Pearls may be used as the foundation for a specific topical discussion such as medical adherence or discharge planning. We also recommend inviting students to share recent (or ongoing) clinical experiences then selecting the most relevant Pearls to shape clinical care. An example is below:
Student: “I saw that chronic pain patient again in my continuity clinic. I feel bad for him but he just keeps asking for more and more pain medication. Do we really believe his pain isn’t controlled? I think it might really be depression or some other psych issue. How do I figure this out?”
Facilitator: “Good question – and a very tough situation. Let’s pull out the SBS Pearl on chronic pain. What ideas does it give us for the care of this patient?”
Student: “I could start asking him to rate his physical pain AND his emotional suffering. That might help him to start differentiating between the two. Oh, and we haven’t even thought of a pain med contract or pain panic plan. We can try those too…..”
• Chalk Talks
Both residents and students often present brief, somewhat didactic “chalk talks” covering aspects of medicine most germane to the patients their team might see. Chalk talks are typically pithy, evidence-based summaries rich with clinical examples. Each Pearl was essentially conceptualized as a pre-made chalk talk – i.e. each one could be pulled, presented to a team, and then illustrated with a clinical example of a current case. If time permits, the scientific basis of each Pearl can be expanded using the recommended readings at the end of each topic.
• Case Conferences
Relevant SBS issues will vary greatly depending on the case being discussed. Faculty/residents might prepare several prompts to remind students to include SBS factors that might influence diagnosis (e.g. current substance use), acute management (e.g. needs interpreter, is under-insured), or discharge planning (e.g. no family supports, no financial resources, copes by withdrawing, tendency for non-adherence). As in case presentations (below), students will need to learn when to highlight particular SBS issues.
• Student Case Write-Ups/Chart Notes
All clerkships require some amount of student charting regarding patient interviews and clinical care. Some clerkships require formal case write-ups. It is impractical to include all psychosocial variables and could even detract from other essential information. As with case presentations, students should be assisted in identifying what SBS factors should be included in several written formats – e.g. chart notes, discharge summaries, and/or more formal case write-ups for teaching purposes.
• Student Case Presentations
Collecting, synthesizing, and presenting patient data is a critical skill developed in the third year. Data on SBS factors is oftentimes relevant and should be part of most case presentations – e.g. current substance abuse, language ability, homelessness, low socioeconomic status, religious beliefs that forbid particular types of care. Students will need guidance in “filtering” psychosocial data so they can better determine when it is or isn’t a critical issue.
• Teaching Rounds and Other Teachable Moments
Since teaching rounds and other teachable moments are tied to whatever cases are at hand, it is difficult to plan or predict what might be covered on a given day. The Pearls are meant as an easily accessible resource to inform teaching about current clinical cases. A few inpatient examples are below:
Clinical case: 66yo man with CHF exacerbation admitted to medicine 2 days ago. Relevant pearls are:
• Behavior change: is the patient adherent to his medications? Diet and exercise recommendations? Did these factors contribute to this hospitalization, and how can a future hospitalization be prevented?
• Chronic Care Model – what is the chronic care model and how can the inpatient team help establish a comprehensive plan of care for the patient upon discharge?
Clinical case: 54 yo woman with colon cancer admitted to the surgery service for hemicolectomy. The patient is Spanish speaking and does not have a primary care physician. Most relevant pearls are:
o Health literacy - What is her understanding of her disease and the planned treatment? Do her children understand the implications for them of this family history of colon cancer?
o Language: Is an interpreter needed? How can accuracy and efficiency be maximized when using an interpreter? Is it ok just to use a family member to interpret?
o Stress and Coping: surgical outcomes including need for pain medications have been linked to pre-surgery stress levels and maladaptive coping. How is this patient coping? How can you help her cope more effectively before the surgery?
• Team Meetings/Discharge Planning
Although much of inpatient medicine is about diagnosis, stabilization, and acute management, students quickly learn that disposition planning is complex and fraught with challenges. If not done properly, patients quickly relapse and may be seen again even within the same rotation. The Pearls can be used to bring key psychosocial factors influencing discharge to the forefront. Examples might include the following:
o Discharge planning and health system resources: Who are the key members of the health care team that should be included in the discharge planning process? Discharge planning: What are the risk factors for an adverse event or re-hospitalization?
• Case conference
o The student presents a case at student case conference of a 65 year old man who was admitted to the hospital abdominal pain and distension diagnosed with chronic hepatitis B and hepatocellular carcinoma. The patient speaks Cantonese. He drinks alcohol 4 -6 drinks per day. The student prepares a talk to present at the end of the case discussion. Potential topics: Alcohol cessation counseling [Behavioral change pearl]
o What resources are needed for a patient with a new diagnosis of cancer? Which physicians should follow him up after discharge? [Discharge planning pearl]
o What is the patient’s understanding of his disease, and how will that affect his treatment? [Explanatory Model of Illness pearl]
Outpatient/Clinic Precepting
All though SBS issues are relevant both in inpatient and outpatient settings, the outpatient clinic probably provides the best opportunity to reinforce and use the SBS concepts described in the Pearls. Preceptors can ask guided prompts to assist learners in exploring these issues and practicing these skills. For example:
Preceptor: Do you think this patient is ready to stop smoking? How did you determine that? [Behavior Change Pearls]
Preceptor: This patient is on 2 antihypertensives but still has a blood pressure of 140/90. Do you think he’s taking his medication? How can you be sure the adherence information you get is accurate? [Medical Adherence Pearl]
Preceptor: You mentioned your patient is under a great deal of stress right now. What does she do to cope that is helpful? In what unhealthy ways is she trying to cope? [Stress and Coping Pearl]
Preceptor: You mentioned this patient is taking ginkgo biloba to improve memory. How can you find out about the efficacy of this supplement? Is it safe? What do we need to worry about? [CAM Pearl]
WHAT PREPARATION DO FACULTY/FACILITATORS/USERS NEED?
Faculty, faciltators, housestaff, students and other users of the toolbox, should:
• Familiarize themselves with the SBS curriculum that occurs in their medical school curriculum: in the preclerkship years and in the clerkship experience
• Identify which pearls in the toolbox are relevant or how they can be adapted to their particular setting
• Select those potential curricular settings (see above) that may be relevant for using the toolbox
• Identify specific educational objectives and methods for implementation for that curricular setting
IS THE PEARLS TOOLBOX EXHAUSTIVE?
No. We attempted to select those that could be applied across clerkship settings, rather than focus on content areas specific to individual clerkships or general physician-patient interaction skills that are not within the exclusive purview of SBS. While additional pearls will be added, it will be important to keep the toolbox in a manageable form. We welcome feedback on revising the current pearls and creating new ones to include.
WHAT ARE THE LIMITATIONS OF THE TOOLBOX?
This Toolbox reflects SBS topics covered in the first two years at UCSF School of Medicine that are most relevant to patient care across core clerkships. However, it is not exhaustive for our context, let alone other settings. We realize that the topics chosen may limit the generalizability of the toolbox. However, we hope that the majority of the topics represent what most medical schools now or in the future will include in their Social and Behavioral Science curriculum. We hope that feedback from those who use this toolbox will allow us to revise the content and focus of the clinical pearls in future versions. We plan to update the Toolbox on an annual basis to reflect changes in the field and new references/resources.
George Saba, PhD & Jason Satterfield, PhD
Adherence: Skills for the Clinician – SBS Clinical Teaching Pearls
Social & Behavioral Science Curriculum Theme
Definitions: Medical adherence includes any of the following:
1) adherence to therapeutic regimens, such as medications or procedures;
2) adherence to health-promoting behaviors, such as diet, exercise, health screening, and immunizations;
3) avoidance of health-compromising behaviors, such as smoking or alcohol/drug abuse; and
4) provider adherence to therapeutic guidelines or universal precautions.
Important elements:
• Non-adherence is a major problem: A third or more of patients do not take their medications as prescribed or follow through on needed medical appointments. The cost non-adherence is $100 billion and leads to spread of disease and emergence of drug resistant organisms.
• Physician Assumptions: We often assume that:
1) Correct treatment was prescribed which was error free and reflects current medical knowledge;
2) Prescribed treatment will fit patient’s life and goals; and
3) Patient’s should follow medical advice.
Be sure to check these assumptions and adjust them accordingly!
Clinical Pearls:
• Assume non-adherence for every patient and ask about it:
• If new patient or uncertain about rapport, do not focus immediately on adherence but inquire about goals, social history and beliefs about illness first.
[pic]
• Use this new data to create a “Differential Diagnosis of Non-Adherence”
1. Primary causal categories for non-adherence usually include:
▪ Medication (shape, size, taste, route of administration, dosing, side effects, cost, stigma, number of meds)
▪ Patient (beliefs, personality, education, family and personal history, memory, eyesight, mood, motivation, language, literacy)
▪ Disease (chronicity, symptoms, consequences of non-adherence)
▪ Provider (dislike pt, burnout, use of medical jargon, doubt treatment usefulness)
2. Check your differential diagnoses with the pt to see if s/he agrees. Brainstorm ideas together on how to address (and correct) the primary cause for non-adherence – e.g. If cost was the primary factor, switch to a cheaper agent or use a formulary drug. If memory is the issue, think of mnemonics like pill alarms, post-its, location of the pill bottle, etc. Remember that this is a shared challenge.
• Other Interventions to Promote Adherence
o Educate the patient about his/her disease and the importance of adherence.
o Simplify the med regimen (fewer daily doses, combo pills) and provide written instructions.
o Have pt repeat back instructions to check comprehension.
o Use meds with longer half-life or meds more “forgiving” of missed doses.
o Enlist the help of family members or friends.
o Consult/gather more information about different beliefs.
Key References/Resources
Osterberg L, Blaschke T. Adherence to medication. N Engl J Med 2005;353:487-97.
George Saba, PhD & Jason Satterfield, PhD
Behavior Change: Skills for the Patient – SBS Clinical Teaching Pearls
Social & Behavioral Science Curriculum Theme
Definitions: Behavior change skills for patients represent strategies to help them change health related behaviors, enhance health promoting ones and alter more risky ones. Two key skills that students have been introduced to include: 1) Self-monitoring and 2) Goal-setting.
1) Self-Monitoring: Helps to gather information on baselines about a behavior before setting goals. It allows for identification of the ABC’s (Antecedents, Behavior and Consequence sequences) for health risk behaviors. This identification can promote the selection of appropriate goals for change.
2) Goal Setting: Characteristics of effective goals include:
• Specificity of goals: Specific problems need to be identified before defining a goal. The more specific the goal, the better the patient can monitor their success at meeting it and modify it if necessary.
• Realistic goals: Setting doable goals leads to a greater likelihood of success that improves confidence and self-efficacy.
• Proximal goals: Goals set as daily or weekly goals fare more successful than those set for months or years as they yield immediate feedback, allow revision, and maintain commitment.
• Flexible goals: Modification of goals allows one to accommodate to obstacles in work and social contexts; flexibility in goals allows this modification more easily.
• Ongoing and continuous review of goals: Rather than a one-time process, goals should be ongoing, reviewed and altered when necessary. This allows improved individualization of goals, needed modification and an opportunity to incorporate goals and behaviors into daily lives.
Clinical Example: 46 year old man who is morbidly obese, with hypertension and diabetes comes into clinic. He is interested in losing weight, but is not sure how to begin. He lives with his partner and two young children.
[pic]
[pic]
Key References/Resources
Bandura A & Simon K. The role of proximal intentions in self-regulation of refractory behavior. Cog Th & Rsch, 1977;1:177-193.
Bellach As, Rozensky R, & Schwartz J. A comparison of two forms of self-monitoring in a behavioral weight reduction program. Beh Th, 1974;5:523-530.
Emmons, K. M. (2001) Behavioral and social science contributions to the health of adults in the United States. In Smedley, B. D. and Syme, S. L. (eds), Promoting health: intervention strategies from social and behavioral research. Committee on Capitalizing on Social and Behavioral Research to Improve the Public’s Health. National Academy Press, Washington, DC, pp. 254–321.
Kazdin AE. Reactive self-monitoring: the effects of response, desirability, goal setting, and feedback. J Consult Cl Psych, 1974; 42: 704-716.
George Saba, PhD & Jason Satterfield, PhD
Behavior Change: Skills for the Clinician – SBS Clinical Teaching Pearls
Social & Behavioral Science Curriculum Theme
Definitions:
Health Related Behaviors: Patients can engage in behaviors that increase their risk for disease (e.g. smoking, drinking alcohol, drugs, unsafe sex, poor diet, lack of physical activity) or promote health (e.g. exercise, sleep hygiene, medical adherence). Health Related Behaviors account for nearly 50% of premature morbidity and mortality (McGinnis & Foege, 2004).
Transtheoretical Model (stages of change): Behavior change is a dynamic process that progresses through stages of readiness: Pre-contemplation, contemplation (change in 6mo is possible), preparation (change in 1mo), action, maintenance, and lapse. Clinical interventions should match a patient’s stage of readiness.
Motivational Interviewing: A collaborative method of identifying a patient’s current stage of readiness and the reasons/values that place them there. “Processes of change” are utilized to move a patient closer to action – e.g. discussing pros/cons of a behavior, rating importance and confidence on a 1-10 scale, keeping a smoking diary to identify triggers and obstacles. (See sample dialogue below.)
5As: The US Preventive Services Task Force recommends the strategy of the 5As as a counseling framework to help patients change unhealthy behaviors:
• Ask about the health risk behavior (e.g. tobacco use, drinking alcohol).
• Advise to make change through clear personalized messages (e.g. identify clear risks to their health of continued engaging in the behavior).
• Assess willingness to change (e.g. identify stage of change).
• Assist patient family to change (e.g. through motivational interviewing and other therapeutic interventions).
• Arrange follow-up and support (e.g. identify a clear plan to maximize long term change and support.
[pic]
Clinical Pearls: Assessing Importance and Confidence in Changing Health Related Behaviors
In addition to assessing stage of change, gathering information about patients’ perceptions of importance and confidence helps you ascertain patients’ current level of motivational readiness, and then be able to tailor the remainder of the dialog. Importance assesses what patients believe about the necessity or value of taking action, while confidence assesses what patients believe about their ability to adopt or change a behavior despite obstacles or barriers (their “self-efficacy”).
For Importance ask: “On a scale of 1-10, how important is it for you to stop smoking?...You gave it a 4. Why not lower? What would make the score higher?” If importance is low (less than 7-8), the clinician should work to increase this rating such as providing information, exploring patient/family medical history and links to the health related behaviors, etc.
For Confidence ask: “On a scale of 1-10, how confident are you that you will be able to stop smoking? You gave yourself a 3. Why not a 2? What would get you to a 4 or higher?” If low, a discussion of past quit attempts, friends who have succeeded, and/or other successful behavior changes might help boost confidence. Breaking off a small step (e.g. homework to monitor smoking, measure cravings, read materials) might give a patient a success experience and build confidence.
Clinical Pearls: Decisional Balance.
Explore a patient’s knowledge, past experience and beliefs about the pros and cons for change and the pros and cons of not changing (i.e. the decisional balance 2x2 table). This will provide important data on what motivates a patient to continue smoking and what “hooks” you might have to motivate change. Patients will not change their behavior until they see that the pros of changing outweigh the cons.
Key References/Resources
A clinical practice guideline for treating tobacco use and dependence: A U.S. Public Health Service Report - JAMA, 2000, vol. 283, p. 3244-3254
Cancer Prevention Resource Center. Transtheoretical model. Available at ; Instructions: Upon arriving at the University of Rhode Island website, please type Cancer Prevention Research Center Transtheoretical Model in the Search Box. The first listing will take you to the Cancer Prevention Resource Center’s web page which immediately lists multiple resources about the Transtheoretical Model. 30 January 2008.
McGinnis JM, Foege WH. The immediate vs. the important. JAMA. 2004;291:1263-1264.
Miller WR, Rollnick S. Motivational interviewing: resources for clinicians, researchers and trainers. Available at ; 30 January 2008.
Rodnick J, Shore WB. The data base: the medical history, physical examination, and write up (6th ed.). San Francisco: University of California, San Francisco, 2007.
Jason Satterfield, PhD, Joyce Chu, PhD
Biopsychosocial Model—SBS Clinical Teaching Pearls
Social and Behavioral Science Curriculum Theme
The Biopsychosocial Model:
• Modern medicine operates within the biomedical model in which disease (i.e., pathology, biological symptoms & signs) is synonymous with illness (a person’s individual experience of that pathology) – in other words, etiology, prognosis, and treatment are considered to be almost entirely biologically determined.
• Evidence shows that over 60% of premature mortality is attributable to behavioral, social, and environmental factors (McGinnis et al., 2002). Ignoring these factors lowers the quality of medical care.
• A biopsychosocial formulation identifies and integrates biological, psychological-behavioral, and sociocultural data essential for the effective treatment of the whole person. This more complete and multi-layered formulation guides treatment selection, promotes medical adherence, and improves clinical outcomes.
What Is A Biopsychosocial (BPS) Formulation?
A BPS formulation is an integrative, working hypothesis about a patient and how s/he is adapting to illness. It includes a comprehensive understanding of the precipitants, causes, and maintaining factors of a patient’s problems. This integrative hypothesis, drawn from biological, psychological, and social factors, guides treatment selection and informs prognosis. The BPS formulation integrates and informs rather than simply summarizing and reporting. It goes beyond the Social History to integrate the biological and physiological aspects of the patient with their psychological and social.
The BPS Formulation can:
• be created by medical students on any clerkship (e.g., inpatient, outpatient); can utilize patient/family sources along with information gathered by other health care professionals on the team.
• be relevant with any patient (e.g., adult, pediatric, prenatal)
• occur at any point in the care (e.g., following admission/intake, prior to discharge).
• develop over time (e.g., during the course of the admission; over a couple of outpatient visits)
• be charted in the patient’s medical record.
Guidelines for The BPS Formulation
Step 1: Assessment: elicit and organize important patient information during the medical interview including
a) Biological (e.g., chief complaint, history of present illness, past medical history, medications, allergies, review of systems, physical and neurological examinations, diagnostic studies)
b) Psychological (e.g., emotions, cognition, personality, stress/coping, health related behaviors)
c) Social (e.g., culture, identity, socioeconomics, social supports, language, literacy, spirituality, environment/neighborhood/community, mobility, resources [financial, transportation, housing, insurance, healthcare access)
Step 2: Formulation and Diagnosis: integrate information from Step 1 into working hypotheses about the causes of patients’ presenting problems and possible diagnoses. This narrows a differential diagnosis, may inform etiology, and helps in Step 3, treatment planning.
Step 3: Treatment Plan: using the BPS formulation, address the patient’s chief complaint and/or highest priority medical needs with biomedical, psychological, and sociocultural interventions. A BPS-informed plan includes typical biological interventions (e.g. medications) but also includes education, enlisting social supports, connected with social work, and addressing obstacles to treatment.
Jason Satterfield, PhD, Joyce Chu, PhD
Biopsychosocial Model—SBS Clinical Teaching Pearls
Social and Behavioral Science Curriculum Theme
Clinical Example
55 year old woman who has had repeated elevated BP readings in controlled settings.
Step 1: Assessment:
Start with developing a diagnosis and/or diagnostic hypotheses. Key symptoms that aid in making the diagnosis may be biological, psychological (e.g. her low mood), or sociocultural (e.g. social isolation). Although no formulation is needed to make the diagnosis of hypertension with this patient, additional information is essential in ruling out other causes (thyroid, anxiety), identifying contributing factors (diet, obesity, stress), and assessing willingness to accept treatment.
Formulation: This hypertensive patient has an extensive family hx of high blood pressure and believes that physicians only care about handing out pills that mostly don’t work and cost lots of money. She is interested in herbal remedies and stress reduction but still a little scared about having a stroke some day. She’s not quite convinced she has high blood pressure. She’s an avid reader and writer who likes to be in charge. A single parent of three adolescents, she has little social support except from her church community. She acknowledges stress at her job. She is bilingual in Spanish and English, emigrated from Mexico as a young adult, and has a moderate level of health literacy.
Plan: You identify that she has multiple strengths, is concerned about her health and wants to be an active partner in her own health care. Together, the two of you design a blood pressure diary where she will record her BP, diet, stress, and other factors she deems important. She will also include any interventions such as herbal remedies or stress reduction. You also give her some good web sites to read more about blood pressure. You order additional laboratory tests to rule out other biological factors affecting her blood pressure. You set up a follow-up appointment where the two of you will go over her diary and discuss what she has learned about BP.
References:
Campbell WH, Rohrbaugh RM. (2006). The Biopsychosocial Formulation Manual: A Guide for Mental Health Professionals. New York: Routledge.
Engel, G.L. (1977). The need for a new medical model: A challenge for biomedicine. Science, 196, 129-136.
Engel, G.L. (1980). The clinical application of the biopsychosocial model. American Journal of Psychiatry, 137:535-544.
Gabbard GO, Kay J. The fate of integrated treatment: Whatever happened to the biopsychosocial psychiatrist? Am J Psych. 2001;158(12): 1956-63.
Leigh H, Nair B. Biopsychosocial rounds presentation format. UCSF-Fresno Medical Education Program, Psychiatric Consultation-Liaison Service. Unpublished manuscript.
McGinnis JM, Russo PG, Knickman, JR. Health Affairs, April 2002.
Ross, DE. A method for developing a biospsychosocial formulation. Jrnl of Fam and Child Studies. 2000;9(1):1-6.
Maria Wamsley, MD
Clinical Teaching Pearls: Chronic Care Model
Social and Behavioral Science Curricular Theme
Definition: The Chronic Care Model (CCM) is a well-described model for improving chronic illness care. It can be applied to a variety of chronic illnesses (CHF, Diabetes, Asthma, Depression), health care settings and target populations. It identifies 6 essential elements of a health care system to provide high-quality chronic disease care. These are:
• Community resources
• Self-management support
• Decision-support
• Delivery system design
• Clinical information systems
• Health-care organization
Clinical Relevance:
Approximately 50% of the population has a chronic illness. About 25% have more than one illness.
Current chronic illness care is uncoordinated, non-evidence based, lacks continuity, and fails to train patients in how to self-manage their illnesses.
A multidisciplinary, proactive team approach that includes the patient and the community is required to best improve the care of chronic illness.
Clinical Recommendations:
Use interviewing strategies such as “ask-teach-ask” and “teach back” to promote patient understanding of their disease. Ask patients what they know, teach additional information, then ask further questions. At the end of a teaching segment, ask the patient to repeat back what they understood - correct as needed.
Promoting Self-Management: Use what students have learned regarding patient education and behavior change to provide self management support to patients and families. There are 4 categories of tasks that pts must perform:
o Manage the illness (taking meds, monitor glucose, use inhalers, etc)
o Carry on normal roles and activities
o Manage the emotional impact of the illness
o Promote health and prevent additional illness
Use an interdisciplinary team that includes psychology, social work, nutrition, pharmacy, etc.
Use decision support tools to practice evidence-based care. Share guidelines with patients and create regular reminders for recommended interventions and screenings. Remember to be sensitive to patient language and literacy issues.
Clinical Pearls:
Inpatient/Acute Care Setting
Acute illness may motivate patients to make behavioral changes
Opportune time to link patients to effective community/institutional resources and outpatient care team
• Opportune time to educate patients/family about their illness and begin to provide them with skills to manage their own illness
Outpatient Setting
Link patients with community resources
Focus on providing patients with knowledge and skills to help them manage their own illness
• Utilize other members of your care team effectively (nurses, case managers, social workers, pharmacists)
Consider system improvements to improve quality of care delivered
Key Questions to Ask
• Tell me what you know about your illness. What are the main symptoms/effects? Why is it important? What happens if it is not treated?
Tell what things you currently do to manage your illness. How well is that working for you?
What gets in the way of taking care of yourself/your illness? What helps?
Who are the members of your health care team? How can they help?
How stressful has this illness been for you? How does it affect your life? How are you coping?
• Tell me how I can best support you in managing this illness. Let's set some realistic goals and talk about how to get there together.
References/Resources
Bodenheimer T, Wagner EH and Grumbach K. Improving primary care for patients with chronic illness: The Chronic Care Model Part 2. JAMA 2002; 288: 1909-1914.
Bodenheimer T, Wagner EH and Grumbach K. Improving primary care for patients with chronic illness. JAMA 2002; 288: 1775-1779.
Goetzel, et al, 2005. Ozminkowski RJ, Villagra VG, Duffy J. Return on Investment in Disease Management: a Review. Health Care Finance Rev 2005; 26(4):1-19.
Karen E. Hauer, MD
Chronic Pain – SBS Clinical Teaching Pearls
Social and Behavioral Science Curriculum Theme
Introduction
Chronic pain is a common complaint where psychosocial factors may play complex roles in etiology, exacerbations, and/or coping. Because pain and psychosocial factors related to pain are often under recognized and under treated, it is critical to assess for pain and related factors in all patients in order to develop a comprehensive approach to management.
Definitions: Chronic pain is pain that continues after healing is complete or for at least three months. Diagnosing chronic pain is difficult because its signs are more subtle than with acute pain. Insomnia, loss of appetite, apathy, irritability, and depression predominate, but autonomic activation is absent. Chronic pain results in a complex psychological disturbance that potentiates the pain, resulting in a self-perpetuating cycle. Because of these cognitive effects, chronic pain responds poorly to standard analgesic therapy alone and requires a multifaceted approach.
Clinical Pearls:
Assess both physical pain and emotional suffering: Pain is inherently subjective and may include both a physical sensation and emotional suffering. Ask the patient to rate the intensity of the physical sensation using a 1-10 scale (1=least pain, 10=most pain). Ask the patient to rate the intensity of emotional suffering related to the pain on a 1-10 scale. Note that although these two ratings are often correlated, a patient may have intense physical pain with little emotional suffering or vice versa. Both the physical pain and emotional suffering should be treated.
Focus on improving quality of life and level of functioning: While pain itself cannot always be eliminated, pain management should be directed toward improving quality of life, restoring productivity, and resuming normal function in society.
o Ask how the pain is interfering with everyday life. Consider PT or OT or other support aids to improve functioning (e.g. support brace, walker).
o Ask what practical things you can do that would most improve the patient’s quality of life – e.g. explain pain to significant other, write a note to employer, refer to water aerobics.
Create a “Pain Contract”:
Collaboratively develop a pain management plan with the patient and all involved providers. The plan should outline the use of medications, medical procedures (e.g. injections), and other non-pharmacologic therapies. Pain contract might include ongoing pain ratings and evaluations of the efficacy of indicated treatments. Contracts also typically include guidelines on the safe use of opiates and procedures to manage lost medications, early refill requests, etc.
Create a “Pain Panic Plan”:
Patients should anticipate exacerbations of pain by creating “panic plans” for breakthrough pain – i.e. allowable changes in medications, support people, and behavioral strategies for periods of intensified pain. This type of planning enhances quality of life by arming the patient with self-management strategies that can obviate unnecessary suffering or visits to the ER.
Consider Multidisciplinary Pain Centers: The complexity of chronic pain management is frequently beyond the expertise of a single practitioner. Multidisciplinary pain centers provide services that allow effective assessment, diagnosis, and therapy of chronic pain syndromes. Practitioners from multiple specialties are available to provide invasive or cognitive therapies that are outside the realm of primary care.
Shelley Adler, PhD
Complementary & Alternative Medicine – SBS Clinical Teaching Pearls
Social and Behavioral Science Curriculum Theme
Definitions: Complementary and alternative medicine (CAM) is the term chosen by the National Institutes of Health. CAM is defined as the “broad range of healing philosophies, approaches, and therapies that mainstream Western (conventional) medicine does not commonly use, accept, study, understand, or make available.” CAM therapies may be used alone, as an alternative to conventional therapies, or in addition to conventional, mainstream medicine to treat conditions and promote well-being.
Clinical Pearls: Communicating with Patients about CAM
Of those patients who see both an MD and a CAM practitioner, the overwhelming majority seek care from their physician before they see an alternative provider. Discussions about CAM offer valuable opportunities to explore a patient’s health care beliefs and concerns. A lack of communication is potentially dangerous, since some CAM therapies can interact adversely with conventional treatments.
Suggestions for talking with patients about CAM.
(Adapted from Hughes & Folkman, Table 30-3; citation below)
1. Ask if the patient is considering or using CAM, using specific examples.
“Many patients use a variety of alternative medicines for their health. Are you taking any herbs such as ginkgo, or seeing a practitioner such as an acupuncturist?”
2. Explore patient’s concerns and wishes that led to interest in CAM.
“Tell me more about this therapy.”
“Can you share with me how you hope this therapy will help?”
“You mentioned that this medicine helps people feel more energy. Have you been feeling less energetic lately?”
3. Establish a connection with the patient. Help identify, validate, and reflect back underlying
emotions/concerns to the patient.
“It’s clear that you’re interested in improving your health.”
“I sense that using something ‘natural’ is important to you. Is that right?”
“It sounds like you’re experiencing some difficulty with this prescription and might prefer something with fewer side effects. Is that true?”
4. Acknowledge that there is often inadequate information about safety and efficacy to guide clinical
decision making.
“Why don’t you bring in the information you have gathered about this therapy, so we can go over it together?”
“Even though there aren’t a lot of data available, we can work to make a plan together.”
5. Identify good resources (see “Resources,” below).
6. Explore potential risks and benefits of CAM (to the extent that they are known) with the patient, as
well as how CAM might interface with ongoing care.
“From what we found out about this supplement, it looks like it will be safe for you to add into your program of a low fat diet and exercise.”
7. Encourage the patient to keep a diary of symptoms, and schedule follow-up for ongoing assessment of
safety and efficacy.
“If you’re willing to keep track of your blood pressures at home as you start this new supplement, we can see if it has any effect. If your pressure starts to go up before our next appointment, I’d recommend you stop the supplement and give me a call.”
8. Be clear when you are concerned that a CAM intervention may be harmful.
“I care about your well-being and understand your desire to stop your prescription medication and start this herbal therapy. This is a difficult situation, though, because I feel that there are some dangers associated with this.”
“I want to support you in your desire to lose weight, but I’m worried that this medicine could be harmful to your health. How do you think we could best work together on this?”
Key References/Resources
Book Chapter
Hughes, E., & Folkman, S. (2008). Complementary and Alternative Medicine. In M. Feldman, J. Christensen (eds.), Behavioral Medicine in Primary Care: A guide for clinical practice (pp. 323-29). New York: McGraw-Hill.
Databases
CAM on PubMed
A subset of the Medline database which provides access to citations on complementary and alternative medicine.
Cochrane Library
Includes six databases that include evidence-based reviews of a variety of alternative medicine modalities.
Natural Standard
An outstanding, evidence-based, easy-to-use database of herbs and supplements, available for free from any UCSF computer.
Websites
Federal Trade Commission
or 1-800-FTC-HELP
The Federal Trade Commission site is for reporting fraudulent product claims.
Food and Drug Administration Medwatch Program
or 1-800-FDA-1088
The FDA Medwatch Program is for reporting adverse medication reactions.
NIH National Center for Complementary and Alternative Medicine
George Saba, PhD
Depression—SBS Clinical Teaching Pearls
Social and Behavioral Science Curriculum Theme
Screening: Given prevalence rates, screen all patients. US Preventive Services Task Force (2002) recommends asking two simple questions. One positive answer triggers a full diagnostic assessment.
"Over the past 2 weeks, have you felt down, depressed, or hopeless?"
"Over the past 2 weeks, have you felt little interest or pleasure in doing things?"
Diagnosis: SIGECAPS: A Mnemonic for Symptoms of Major Depression NOTE: For the diagnosis, must have 4 symptoms plus depressed mood or anhedonia, most of the day nearly every day for at least two weeks.
Sleep disorder (either increased or decreased sleep)*
Interest deficit (anhedonia)
Guilt (worthlessness,* hopelessness,* regret)
Energy deficit*
Concentration deficit*
Appetite disorder (either decreased or increased)*
Psychomotor retardation or agitation
Suicidality
Clinical Pearls:
A. Medical Interview
• Build trust by responding to distress (Cole et al, 2007)
o “You look sad right now; You seem to be dealing with a lot of stress; is that true?”
• Use direct and open-ended questions; focusing on anhedonia and depressed mood first
o “What have you enjoyed doing recently?”
o “How have you been feeling?”
• Inquire about past history of mood disorders, other mental illness, and/or suicidality; always screen for concurrent substance abuse (“self-medication).
• Involve the family to gather information about patient’s emotions, behavior, and interactions
• Normal practice is to call for psychiatric consultation (“Psych Consultation and Liaison Service”)
B. Suicide risk assessment
Depressed patients should be screened for suicide risk. Assess for ideation, plan, and intent (and/or call for Psych Consult to do the assessment for you.) Past suicide attempts, impulsivity, substance abuse, and social isolation increase risk of suicide.
1. Ideation (passive or active): “In the past 2 weeks, have you had thoughts you would be better off dead (passive ideation) or of actively hurting yourself in any way (active suicidal ideation)?”
2. Plan: “Have you thoughst about how you might actually hurt yourself? If yes, please describe.”
3. Intent: “Do you think you might carry out your plan? Is there any risk of becoming upset and acting on your plan?”
Crisis Resources: All patients with ideation should be given the relevant crisis numbers. Patients with ideation plus plan should be given the numbers and scheduled with an urgent psychiatric appointment within 48-72 hours. Ideation+plan+intent is an emergency.
• Identify relevant local resources and telephone numbers
o Suicide Prevention Hotline
o Psychiatric Emergency Services at teaching hospital
1. General Emergency Assistance (24hrs) Dial 9-1-1
In an Emergency: Suicidality (ideation+plan+intent) is a medical emergency just like any other. Ensure immediate safety of patient as well as family/friends and staff who are in proximity. Get patient to an emergency room asap = call 911 or Institutional police
C. Treatment Approach
• Consider treatment modalities-psychotherapy and/or medications
• Provide disease education and discuss appropriate treatment options with patient/family
• Educate/prepare patient for treatment
o Provide justification/need for treatment, use chronic disease management analogies
o Inform patient that initial results from psychotherapy and/or medications may take 4-6 weeks then require adjustments to dosage. Medication side effects may be noticed immediately.
o Stress need for daily adherence to medications and/or therapy homework
o Provide referrals to psychotherapy or other treatment as needed.
Key References/Resources
Cole SA, Christensen, JF, Cole MR, Cohen H, Feldman MD Depression. In M. Feldman & J. Christensen
(Eds), Behavioral medicine: a guide for clinical practice. New York: McGraw Hill, 2007, 199-206.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR.
Washington, DC: American Psychiatric Association; 2000.
Pignone M, Gaynes BN, Rushton JL, et al. Screening for Depression. Systematic Evidence Review No. 6
AHRQ Publication. No. 02-S002. Rockville, MD: Agency for Healthcare Research and Quality, May
2002.
Whooley MA, Avins AL, Miranda J, Browner WS. Case-finding instruments for depression: Two
questions are as good as many. J Gen Intern Med 1997;12:439-45.
Dana Hughes, DrPH
Discharge Planning – SBS Clinical Teaching Pearls
Social and Behavioral Science Curriculum Theme
Introduction:
The scope and quality of care patients receive post-hospitalization can support or undermine the benefits of care provided in hospital. Planning for patient needs after release is critical to ensure that patients have the support and assistance, resources and information to achieve the best outcome. Hospitals typically have discharge planners on staff, but students can facilitate and enhance this process by anticipating needs, asking questions of patients and their families, and identifying community resources.
Components of Planning for Discharge: Following hospitalization, many, if not most, patients need follow-up care or treatment and/or support services. In addition to understanding the patient’s needs (determined by diagnosis and prognosis, mental/emotional state, the availability of social supports, need for other social services, income and health insurance, etc.), students need to know about the availability of the services (private vs. public/community, rural vs. urban, etc.) and the patient’s access to them (determined by income and insurance status, language spoken, geography, etc.).
Clinical Pearls:
• Ensure that the patient understands their condition and the instructions for post-hospital care (medication use, outpatient treatment, follow-up care, etc.)
o Check for understanding about the condition, medications and other health information, including follow-up care, by using methods such as “teach-back” (i.e., recipient of the health information is ask to restate the information in his/her own words).
o Equip the patient with information about who to call if questions arise after discharge.
o Ensure that the patient has a primary care provider/“medical home” for follow up care and that information about the hospitalization is conveyed to that provider. For patients without a primary care provider, contact patient referral or the general medical clinic at the hospital where the patient is currently receiving inpatient care.
• Know the patients’ insurance status (and type of insurance, especially public v. private). Access to outpatient services and medications can be significantly limited without health insurance. Access can also vary by types of both public and private insurance. Knowledge about the patient’s coverage and the resources available with that coverage is essential to planning for post-hospital care.
• Determine if (and what) support or social services will be needed. Consider:
o The circumstances under which patients will live after discharge (e.g., with family or neighbor support to help administer meds, drive to appointments, cook meals, etc., or independently/in isolation? Lives in a community rich with health and social services or geographically far from such resources?);
o The patient’s degree of mobility and living circumstances. If the patient is frail or deconditioned, determine if assistance is available to get around, navigate stairs and avoid falls;
o The mental/emotional state of the patient and ability to cope with the added responsibilities of care after discharge (e.g., fear/acute concern about their health condition);
o Other needs such as language interpretation, accommodation for physical disabilities, nutritional services, etc.;
o Legal requirements for follow-up, such as conditions involving family violence, as well as legal requirements for reporting certain infectious diseases to the health department.
• Identify resources for the patient after discharge (or at least offer concrete guidance about how to obtain needed services).
o Within the hospital, seek the advice of social workers for assistance in identifying community resources, liaising with legal entities such as child services, and working with a patient around financial issues related to health care.
o Outside of the hospital, a primary resource is the county public health department (e.g. public health nursing, for general referrals and specific public health offices for specialized referrals such as mental health counseling, food/nutrition services, infectious disease control, lead abatement services, sexually transmitted diseases, immunizations, prenatal care, and assistance with Medi-Cal or Healthy Families for health insurance, etc.).
Key References/Resources
Discharge Planning for Hospital Patients. Center for Medicare Advocacy, Inc. October 2008. . Upon arriving at the Medicare Advocacy website, go to the left hand menu and hit “Info by Topic”. Then scroll down to “Discharge Planning”. There will be numerous issues on discharge planning addressed.
Breathing Life Into Discharge Planning,” by Alfred J. Chiplin, Jr., . 22 June 2004. Please follow the above instructions to reach the “Discharge Planning” page. At the bottom of that page, there is a link to “Older Articles”. This link will take you to a list of articles under the heading of “Hospital”. Under that heading, you will find the article by Alfred Chiplin.
Jason Satterfield, PhD
Explanatory Model of Illness – SBS Clinical Teaching Pearls
Social and Behavioral Science Curriculum Theme
Definitions: “Explanatory Model of Illness” is defined as beliefs the patient holds about his/her disorder, the personal and social meaning s/he attaches to this disorder, his/her expectations about what will happen and what the doctor will do, and his/her own therapeutic goals. A comparison of the patient’s model with the clinician’s model can help identify major issues that might impede or facilitate clinical management.
Important elements:
• Causal explanations: nearly all pts develop an explanation for what caused their illness. This subjective perception greatly impacts behavior (e.g. med adherence, HRB, help-seeking), emotion (e.g. hope, fear, guilt), and cognition (e.g. self-confidence, motivation, meaning).
• Treatment expectations: whether voiced or not, patients come with expectations about what treatment will work for their illness. A mismatch of patient expectations and clinical management is a primary reason for non-adherence. Inclusion of alternative or traditional therapies, doctor shopping, and other patient-initiated treatment strategies are often driven by patient treatment expectations.
• Meaning: subjective perceptions of prognosis, disease course, and meaning help explain patient suffering, impairment, and stigma. Addressing these issues can be highly therapeutic.
• Questions to elicit the patient’s explanatory model:
• General: I know different people have very different ways of understanding illness... Please help me understand how you see things.
• What do you think has caused your problem?
• Why do you think it started when it did?
• What do you think your sickness does to you? How does it work?
• How severe is your sickness? Will it have a short or long course?
• What kind of treatment do you think you should receive?
• What are the most important results you hope to receive from this treatment?
• What are the chief problems your sickness has caused for you?
• What do you fear most about your sickness?
Key ideas to reinforce and/or elaborate:
• A few questions about a patient’s explanatory model can provide critical insight into the patient’s experience of illness and may yield critical data needed to promote medical adherence and active disease self-management. Asking a few questions up front may save substantial time in the long run.
• Eliciting and respecting explanatory models of illness is a key element in understanding and working with patients from diverse cultural backgrounds.
• Although explanatory models can be shifted through competent patient education, it is not helpful to see patient models as inherently “wrong” or “naïve” or “bad.” It is more helpful to explore the health consequences of the models currently held and to negotiate an acceptable treatment plan based on both the patient’s model and the clinician’s model.
Clinical relevance:
• Promotes better medical adherence and appropriate utilization
• Improves the provider-patient relationship and satisfaction
• Enhances communication and negotiation skills
• Facilitates chronic disease self-management
• Essential for culturally competent care
Key References/Resources
Conner, M., Norman, P. (Eds.) (1998). Predicting health behaviour. Buckingham: Open University Press.
Kleinman A. Culture, illness and cure: Clinical lesions from anthropologic and cross-cultural research. Ann Int Med. 1978; 88:251-258.
Lang F, Floyd MR, Beine KL. Clues to patients’ explanations and concerns about their illnesses. Arch Fam Med. 2000;9: 222-227.
Sensky, T. Causal attributions in physical illness. J of Psychosomatic Res. 1997;43(6): 565-573.
Rene Salazar, MD
Health Care Disparities and Provider Bias – SBS Clinical Teaching Pearls
Social and Behavioral Science Curriculum Theme
PROVIDER BIAS AND HEALTH CARE DISPARITIES
Definitions:
• Cultural background/Identity group: includes race/ethnicity, sexual orientation, religion, disability, gender, age, socioeconomic status, etc.
• Health care disparities: unequal health care access, health care quality, or health care outcomes for patients based on their cultural background/identity group.
• Provider bias: Three types: 1) Personal biases about patients of a certain cultural group; 2)Biases in provider knowledge base; 3) Biases in systems of care.
Health care disparities are well-documented. They may occur when clinicians are unaware of provider bias.
Clinical Relevance:
• Health care disparities exist and are well-documented. Ethnic minorities have:
o Lower access to health care (e.g., Lower referral of Blacks for kidney transplant)
o Poorer quality of care (e.g., Underutilization of translation for monolingual immigrants)
o Higher rates of misdiagnosis (e.g., Overdiagnosis of schizophrenia in Blacks)
o Greater disability burden
• Providers can unknowingly perpetuate health care disparities. Under time/resource constraints, providers often take shortcuts, relying on previous experience and assumptions in treatment decision-making.
o Be aware of assumptions made based on race
o Avoid making decisions based solely on racial ID or other group-based assumptions.
• With awareness about provider bias, providers can counteract its negative effects on health care.
Clinical Pearls:
• Questions to ask yourself. Assess personal, systems, and knowledge-based bias with every patient.
o What are my assumptions about this patient and their background?
o Have I made any clinical judgments based on assumption rather than fact?
o What does the literature say about this patient’s identity group and diagnosis? Does this literature apply to my patient?
o What would my diagnosis/treatment be for a patient of a non-minority group with this clinical presentation? If different, is it justified?
o How can I decrease any provider mistrust?
o How should I plan treatment to fit this patient’s cultural context?
• Questions to ask your patient. Ensure fit of treatment with your patient’s cultural context.
o Utilize the Ask-Teach-Ask method to assess for patient understanding
o Ask about any barriers to following through with the treatment (What difficulties or concerns do you have about this treatment plan?)
• Goals are to:
o Provide culturally competent care
o Decrease inequalities in treatment/diagnosis/health care access
Key References/Resources
• Burgess DJ, Fu SS, van Ryn M. Why Do Providers Contribute to Disparities and What Can Be Done About it? J Gen Intern Med. 2004;19:1154-1159.
• Cooper L., Beach M.C., Johnson R.L., Inui T.S. Delving Below the Surface: Understanding How Race and Ethnicity Influence Relationships in Health Care. J Gen Intern Med 2006;21:S21-27.
• Smedley BD, Stith AY, Nelson AR. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Acad Pr; 2002.
Rene Salazar, MD
Health Literacy – SBS Clinical Teaching Pearls
Social and Behavioral Science Curriculum Theme
Definitions: Literacy is defined as “an individual's ability to read, write, and speak in English and compute and solve problems at levels of proficiency necessary to function on the job and in society, to achieve one's goals, and to develop one's knowledge and potential."[1] Health literacy is defined in Healthy People 2010[2] as: “The degree to which individuals have the capacity to obtain, process, and understand the basic health information and services to make appropriate health decisions”. It is not just the ability to read but includes the ability to understand medical brochures, physician instructions, consent forms and medication instructions all needed to negotiate complex health care systems. One’s literacy will impact their health literacy.
According to the literacy report released by the National Center for Education Statistics (NCES) about 1 in 20 adults in the U.S. is not literate in English. 11 million Americans lack the skills to handle many everyday tasks and 30 million adults may not be able to understand a simple pamphlet.[3]Almost half of the US population has difficulty understanding and using health information. Vulnerable populations include the elderly, minorities, immigrants, and low socioeconomic status.
Important elements: Health literacy requires the skills of reading, listening, analyzing, and decision-making and the ability to apply these skills to health encounters.
Clinical Pearls: Several instruments to assess literacy and health literacy exist; however many of these are lengthy and impractical to use in daily clinical settings. Here are some suggestions to assess how much patients understand.
• Check patient retention and comprehension. Use the strategy of ASK-TEACH-ASK [Ask: “What can you tell me about our last discussion regarding high blood pressure”; Teach: “Correct, untreated high blood pressure can lead to several problems including stroke and kidney problems”; Ask: “Do you have any other questions about high blood pressure?”]
• Check for understanding by using methods such as “teach-back”: recipient of health information is asked to restate information in their own words.
• When providing verbal instructions speak clearly and listen carefully. For patients with limited English proficiency use a medically trained interpreter (if available).
• Consider the following questions when providing written health information:
o Is the information easy to use?
Limit the number of messages, use plain language, and focus on action. Supplement instructions with visuals. When writing instructions use large fonts, simple sentences, space between sections and bullet points.
• During patient encounters, take time to review instructions with patients. Carefully review any print materials that are provided to patients.
• Involve other members of the health care team. Pharmacists, nurses, and trained health educators can provide additional support and education to help increase patient’s understanding.
• Follow up with patients after an encounter. A follow up telephone call soon after a clinical encounter provides an opportunity to reassess understanding and allows for the provision of additional information if needed.
Key References/Resources
Health Literacy: A Prescription to End Confusion. Institute of Medicine. 8 April 2004. Available at: iom.edu.
Upon arriving at the Institute of Medicine homepage, please type in Health Literacy in the Keyword Search box. This will bring you to the Health Literacy: A Prescription to End Confusion Report and a PDF brief summary of its contents.
Health Literacy American Medical Society Foundation. American Medical Association. 19 November 2009. Available at: .
Upon arriving at the American Medical Association homepage, please type in Health Literacy American Medical Society Foundation in the Search box. A number of relevant and recent articles will appear.
National Standards for Culturally and Linguistically Appropriate Services in Health Care: [assets/pdf/checked/finalreport.pdf]
Office of Minority Health: []
Merik Gross, MD
Intimate Partner Violence – SBS Clinical Teaching Pearls
Social & Behavioral Science Curriculum Theme
Definitions:
1) IPV is a progressive pattern of assaultive and coercive behaviors that adults or adolescents use against their intimate partners.
2) There can be a variety of forms; the most common include physical, sexual, psychological, and economic (fiduciary).
Key Concepts:
Lifetime prevalence of IPV is 13-30% in population based samples of women and 26-55% of women in health care settings. (MMWR, McGrath). It is associated with many of the leading causes of adult morbidities including depression, chronic pain, substance abuse, CHD and even diabetes (Fellitti). Because emerging research has shown that the prevalence among gay men is similar to that of heterosexual women, guidelines have been established to screen all adolescents and adults regardless of their sexual orientation.
Clinical Pearls:
Use the mnemonic RADAR:
Routinely screen for abuse
Ask direct questions and Affirm feelings
Document patient history and physical exam
Assess patient safety
Review options and Referral
Routinely screen
1) How?
▪ Use a non-judgmental tone
▪ Screen in a private setting
▪ Ensure that you ask when the patient is not in the presence of family members, friends or partners.
▪ Use translation services if there is any question that there might be a language barrier.
▪ Be sensitive of both patient and physician barriers to screening. Victims of IPV are often fearful of escalating violence, loss of financial standing, deportation, and/or loss of custody of their children. They may be ambivalent and have strong reasons to stay in the relationship. The goal is not to “fix” the problem or to get the patient to disclose information or leave the relationship. We must respect the patient’s level of readiness to change his/her situation.
2) When?
▪ Routinely screen at each new patient encounter including all urgent care visits
▪ When suspicious of violence in the home.
▪ Ask as part of the social history
▪ Assessment should not occur if there is a fear for patient or provider safety, or if privacy and/or a translator cannot be secured
Ask direct questions and affirm feelings
1) Ask direct questions
a. “Have you ever been hit, threatened or harmed?”
2) Give messages of support
a. “I am so sorry this is happening to you. No one deserves to be treated this way.”
3) Normalize
a. “Unfortunately, Intimate Partner Violence is very common, and I ask all my patients about it.”
Document clearly using confidential forms.
1) Be specific and objective with your descriptions.
2) Use first and last names of perpetrator and details about his or her location.
3) If available, use your institutional “report of injuries by a deadly weapon or assaultive or abusive conduct” form to insure all necessary information has been documented if required to call the police.
4) Be aware of Reporting Requirements
o Check your state for reporting requirements. For example, in the state of California, reports are triggered by physical evidence of injury.
o A supervising physician must call as soon as possible and mail the report within two working days of the incident.
o Although reports are not required when the disclosed abuse is unaccompanied by physical evidence of injury, they should be completed if requested by the victim.
o Check to see if your hospital has a standardized institutional reporting form that is available for your use and which will prompt you to answer specific questions.
Assess for safety:
1) Begin by stating your concern
• “I am concerned about you and your children’s/ parent’s safety and need to know if there are any weapons in the house.”
2) Ask:
• About imminent danger and the location of the perpetrator
i) “Is your partner in the waiting room, now?”
• About direct homicidal or suicidal threats
• Whether or not weapons are in the home
• Children and elders who might be involved.
Review safety options and give resources
o Determine if your institution has safety planning forms or a means of accessing them. For example, . has safety planning forms available in many languages, along with helpful patient education materials and a list of resources by county in the SF Bay Area.
o Connect patients with a social worker and consider if the particular scenario calls for referral to a shelter. If the patient is ready to seek help, ask the patient if she or he would like to make a phone call in the office to a local shelter
o Always schedule a follow-up appointment
Key References/Resources
Know how to find national and local patient resources:
National Hotline 1-800-SAFE; local shelters, Police Department; District Attorney’s Office
Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Kiss MP, Marks JS.
(1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of
death in adults. American Journal of Preventive Medicine, 14 (4), 245-258.
Rene Salazar, MD
Language – SBS Clinical Teaching Pearls
Social and Behavioral Science Clinical Teaching Pearls
Background: Communication across language barriers is essential to the provision of safe and effective care for diverse populations. English is not the first language for over 40 million Americans and over 20 million speak English poorly or not at all. UCSF provides over 30,000 interpreter visits per year. Language barriers contribute to disparities in health care access and quality and there is research to support that the use of interpreters can decrease these disparities. People with limited English proficiency (LEP) are less likely to have a regular source of primary care, receive preventative care less often and are more often less satisfied with the care they receive.
Title VI of the 1964 Civil Rights Act, which promises equal access to federally assisted programs, requires that recipients of federal assistance provide translation services at no cost to people whose ability to read, speak, or understand English is limited. Health care providers who accept Medicare and Medicaid (MediCal) payment for their services to LEP patients should provide effective language assistance. The Office of Minority Health, Health and Human Services Department issued national standards for culturally and linguistically appropriate service in health care (CLAS standards). These 14 standards include mandates, guidelines and recommendations which inform, guide and facilitate required and recommended practices related to culturally and linguistically appropriate health services.
Importance of language on Medical Outcomes:
▪ Improved functioning and well-being
▪ Improved adherence and satisfaction
Clinical Pearls-Use of Interpreters:
▪ How do you know if an interpreter is needed?
o Offer interpreter services to all patients with limited English proficiency. Providers who are fluent in a second language may not need interpretation services; however, those who are semi-fluent or somewhat fluent should request an interpreter.
▪ How do you access an interpreter?
o Contact interpreter services at each clinic site (SFGH, Parnassus)
o Telephone interpreters available 24 hours a day using ATT. Contact hospital operator.
▪ What are the different kinds of interpreters used?
o Professional interpreters are the gold standard
o Maximizing effectiveness
▪ Meet with interpreter before entering exam room
• Share style preference, discuss potential patient difficulties or tough issues
▪ Introduce self and interpreter to patient-reassure that confidentiality will be maintained
▪ Pay attention to the set up-“triangle” OR place interpreter behind the patient-look at patient directly
▪ When speaking: provide clear organization, avoid jargon, and speak in short segments. Don’t belittle the patient by speaking loudly.
▪ Request interpretation of all patient-interpreter interactions, all MD questions and responses
▪ Look for non-verbal cues and ask for clarification of nonverbal communication if needed
▪ Provide a summary of the major points at the end of the visit
▪ Reaffirm follow up plans and instructions
o Family members as interpreters
▪ Avoid if at all possible. Risks of using family members as interpreters include embarrassment discussing personal issues, family dynamics, lack of objectivity and potential for misinterpretation and abuse.
▪ Children-Includes risks listed above plus concern for age-related language proficiency, emotional maturity, age inappropriate content and confusion of family roles or hierarchy.
o Health Provider using second language
▪ Potential for misunderstanding, diminished empathetic attunement and misperception of nonverbal communication.
o Staff member (e.g. receptionist) who speaks the pt’s language.
o Telephone interpreters (AT&T)
▪ Dual handsets available in patient rooms at Moffitt-Long Hospital
o Video monitors
o American Sign Language (ASL)
Key References/Resources
Jacobs EA, Shepard DS Suaya JA, Stone EL. Overcoming Language Barriers in Health Care: Cost and Benefits of Interpreter Services. Am J Public Health. 2004;94:866-869.
Karliner LS, Perez-Stable EJ, Gildengorin G. The Language Divide: The Importance of Training in the Use of Interpreters for Outpatient Practice. J Gen Intern Med 2004;19:175-183.
Office of Minority Health, U.S. Department of Health and Human Services. National
Standards for Culturally and Linguistically Appropriate Services in Health Care.
Rockville: IQ Solutions, 2001.
Romero, C. Using medical interpreters. American Family Physician. 1 June 2004. Available at
Upon arriving at the American Academy of Family Physicians, type in AFP in the Search box (AFP is the American Family Physician journal of the American Academy of Family Physicians). Once on the AFP web page, type in Using medical interpreters into the Search box. This will bring you to a list of many articles on medical interpreters including this one by Cecilia Romero.
Shane Snowdon & Rene Salazar, MD
LGBT Issues in Healthcare – Clinical Teaching Pearls
Social & Behavioral Science Curriculum Theme
Background: As lesbian, gay, bisexual and/or transgender (LGBT) people move toward legal equality and become more numerous and visible in the population, their particular healthcare needs are receiving increasing attention. Growing numbers of medical institutions are attending to LGBT concerns as they seek to increase their cultural competence and lessen health disparities associated with minority status.
Definitions: “Lesbians” are women primarily attracted to other women, “gay men” are primarily attracted to other men, and “bisexuals” are attracted to both sexes. “Transgender” is an umbrella term referring to those who appear “gender-variant” by prevailing gender norms and/or those who are “transsexuals,” i.e., those who have changed their “gender identity” by transitioning to a sex other than the one assigned to them at birth (often, but not always, via hormones and/or surgeries).
Clinical pearls
LGBT patients tend to delay or avoid healthcare (including annual exams, special consults, screenings, and tests) because of past or current experiences of bias in medical settings, with predictably negative health outcomes.
This tendency can be mitigated in a variety of ways, including:
• Intake forms that allow pts to self-identify as LGBT and provide advance notice of LGBT status
• Interviewing that non-judgmentally asks about (and responds to) LGBT pts’ sexual orientation and/or gender identity: “Thank you for sharing that with me”
• Familiarity with LGBT people and issues on the part of all medical staff via training, reading, and/or web browsing: see Resources below
• Awareness that any pt can be LGBT, regardless of behavior or appearance
Health care professionals may be unfamiliar with some LGBT pt needs
The Resources below offer a wealth of clinical observations, including these:
• Women sexually involved with women should receive pap smears as other female patients
• Men sexually involved with men should receive an annual (or, depending on their risk status, more frequent) sexual risk assessment and follow-up screenings
• Men sexually involved with men should be vaccinated for hepatitis A and B
• Transsexual pts should be screened for the risks associated with their birth sex (e.g., male-to-female transsexuals should be screened for prostate cancer on the same basis as male pts)
• LGBT pts should be offered parenting resources on the same basis as other patients
• LGBT pts should be screened for domestic violence as other pts, and possibly “street violence”
• Many metropolitan areas offer special LGBT-targeted programs focused on smoking, drug and alcohol use, and mental health concerns
• Young LGBT pts experiencing hostility from friends and family may turn to medical professionals for non-judgmental assistance
• LGBT seniors may need special support in interacting with elder care facilities unaccustomed to (and even biased toward) “out” LGBT pts
Key References/Resources
• Gay & Lesbian Medical Association (GLMA):
• Kaiser Permanente Provider’s Handbook on Culturally Competent Care: LGBT Population: call 510-271-6663 to obtain a copy
• The Fenway Guide to Lesbian, Gay, Bisexual & Transgender Health,
published by the American College of Physicians, available at: atpro/timssnet/catalog/books/fenway.htm
• Mravcak S. Primary Care for Lesbians and Bisexual Women. American Family Physician, 15 July 2006, Available at:
Upon arriving at the American Academy of Family Physicians, type in AFP in the Search box (AFP is the American Family Physician journal of the American Academy of Family Physicians). Once on the AFP web page, type in Mravcak into the Search box. This will bring you to the article listed above by Sally Mravcak.
• TransGenderCare: default.asp
• Medical Therapy & Health Maintenance for Transgender Men:
• Knight, D. Health Care Screening for Men Who Have Sex with Men. 1May 2004. Available at:
Upon arriving at the American Academy of Family Physicians, type in AFP in the Search box (AFP is the American Family Physician journal of the American Academy of Family Physicians). Once on the AFP web page, type in Daniel Knight into the Search box. This will bring you to the article listed above by Daniel Knight.
Dana Hughes, DrPH
Maximizing Care in Varied Health Care Systems– SBS Clinical Teaching Pearls
Social and Behavioral Science Curriculum Theme
Introduction:
The sites in which students receive clinical training can vary in terms of the range of formulary, consultative resources and diagnostics that are available, as well as the policies and procedures for obtaining them. This variability also exists with respect to ancillary services, such as social and other patient support services. Understanding the origins of these differences -- but especially how they operate in the setting in which individual students are trained -- is important to maximize efficiency and quality of patient care. Most students receive training in 3 different kinds of health care systems/facilities:
• Large, private hospital
o Payer mix is typically insured, 3rd party payers, Medicare.
• Public hospital
o Payer mix is typically Medi-Cal (Medicaid), Medicare, Uninsured
• VA Medical Center
o Key features, differences, things to consider (e.g. electronic med records, service connection, very few services for women, non-English speakers)
Clinical Pearls:
Familiarize yourself with the hospital’s specific policies and approaches to ordering diagnostics, medications and consultations.
Differences exist between health care settings in terms of the formulary, consultative resources, and diagnostic capacity, as well as the policies and procedures for ordering them. These differences are important to understand so as to avoid ordering tests or medications that are unavailable or seek consultations that cannot be obtained.
Identify individual patients’ insurance status and specific coverage to see how they affect access to medications. labs and/or consultations.
For example, formularies for Medicaid patients may be more restrictive than for privately insured patients. Similarly, hospitals/health systems typically have agreements with health plans to offer only specific medications within a classification. Because these arrangements can vary from hospital to hospital, knowing the patient’s insurance coverage and how that coverage affects access to specific medications prior to prescribing or assisting with prescription fulfillments can save valuable time.
Discover the hospital’s patient support services and how to access them for patients.
Approaches to providing patients with “ancillary services” such as social services, counseling, spiritual guidance, and family support can also vary from hospital to hospital. In some systems, these services are viewed as an integral part of the treatment and healing process while others are less willing to offer more than what is minimally required.
Rely on Attendings, Housestaff, Social Workers and Nursing to help clarify the above issues.
Dana Hughes, DrPH
Medical Errors – SBS Clinical Teaching Pearls
Social and Behavioral Science Curriculum Theme
Introduction:
Medical errors result in as many as 98,000 patient deaths a year and countless more preventable illnesses, injuries and disabilities.[i] They also result in tens of billions of unnecessary health care costs. Medication errors (prescribing and deliverance) are among the most common type of medical error resulting from ordering errors, administering errors, transcription errors and dispensing errors. Other major types of errors include surgical errors and hospital acquired infections.
Medical errors can result from a variety of factors which can be categorized as:
• Communication problems (written and verbal miscommunication within an office, clinic or hospital team, between different components of the health care system and between health care providers working different shifts);
• Inadequate information flow (affecting the availability of critical information when needed for prescribing decisions timely and reliable communication of critical test results and coordination of medication orders at points of interface or transfer of care);
• Human problems (including failure in following policies, guidelines, protocols and processes)
• Patient-related issues (e.g., improper patient identification, incomplete patient assessment, failure to obtain consent and inadequate patient education);
• Organizational transfer of knowledge (e.g., deficiencies in orientation or training and lack of, or inconsistent, education and training for those providing care);
• Staffing patterns/work flow (when physicians, nurses and other health care workers are too busy because of inadequate staffing or when supervision is inadequate, which can lead to situations in which workers are more likely to make an error);
• Technical failures (such as device/equipment failure and complications or failure of implants or grafts); and
• Inadequate policies and procedures.
Clinical Pearls:
Most medical errors are systems-related and not attributable to individual negligence or misconduct.[ii]
Many of the solutions should be directed at the systems-level, such as:
• Use of information technology, such as hand-held bedside computers, to eliminate reliance on handwriting for ordering medications and other treatment needs.
• Avoidance of similar-sounding and look-alike names and packages of medication.
• Standardization of treatment policies and protocols to avoid confusion and reliance on memory, which is known to be fallible and responsible for many errors[iii].
Individual health care providers (including students) can help reduce medical errors:
• Promote communication among team members
o Ensure that instructions and information received are understood and instructions/information delivered is also fully comprehended;
• Check and re-check diagnostic orders, results, prescriptions and delivery instructions;
• Immediately report medical errors (yours and others), known or suspected, to proper hospital authorities.
Identify the hospital/clinic’s policy for informing and communicating with patients about medical errors
Work closely with Faculty Attendings, Housestaff, Student colleagues and health care staff to develop a useful process to reflect on medical errors when they occur:
• Openly communicating about what occurred can reduce unproductive emotions of blame and guilt that can build within clinicians or the treatment team.
Key References/Resources
i Kohn LT, Corrigan JM and Donaldson MS (eds.). To Err is Human. Committee on Quality Health Care in America. Institute of Medicine, National Academy Press: Washington DC, 2002.
ii Ibid.
iii ARHQ. Medical Errors: The Scope of the Problem. Fact Sheet. Publication number AHRQ 00-P037. Agency for Health Care Research and Quality. Rockville MD. http:// qual/errback.htm
Jason Satterfield, PhD
Social Support – SBS Clinical Teaching Pearls
Social and Behavioral Science Curriculum Theme
Definitions: Social support is the physical and emotional comfort given to us by our family, friends, co-workers and others. It is knowing that we are part of a community of people who love and care for us, and value and think well of us.
Two aspects of social support are important to assess for clinical care:
1. Sources of support – the individuals, groups, or organizations that are available to provide support.
2. Types of support – emotional, informational (e.g. advice, problem-solving), and instrumental or practical support (e.g. money, transportation).
Optimal support requires identifying and utilizing the individuals who can provide the type of support the patient needs at that moment.
Clinical relevance:
• Having one or more social supports lowers all cause morbidity and mortality.
• Having more than one close social support does not confer significant clinical advantages but it does provide “insurance” if one of the social supports is lost.
• Initial social support interventions should probably target the most isolated patients and/or those with acutely elevated support needs.
• Quality social supports predict better medical adherence.
• As a predictor of 1-year mortality, low social support is equivalent to many of the classic CVD risk factors, such as elevated cholesterol, tobacco use, and hypertension. Lack of a social support network should be considered a risk factor for subsequent morbidity and mortality after myocardial infarction.
• Social support is associated with cancer survivorship and lowered risk of cancer recurrence.
Clinical Pearls:
• Assess social supports for every patient.
o Who? “Who do you turn to for support? Who is in your life that can help out?”
o What? “What kinds of help can they give you? What kind of support is s/he good at? Who can help with transportation? Money? Filling your meds?”
o When? “Are there times when you don’t have any help? When are your supports able to help out? Are there times when you aren’t able to ask for help even though you need it?”
o How? “How can I help you get the support you need? What has helped/hurt? What have other providers tried so far?”
Key References/Resources
Cohen, S., Kaplan, J.R., & Manuck, S.B. (1994). Social support and coronary heart disease: Underlying psychological and biological mechanisms. In Shumaker, S.A. & Czajkowski, S.M. (Eds.), Social Support and Cardiovascular Disease, pp. 195-221. New York: Plenum Press.
Mookadam, F. & Arthur, H.M. (2004). Social support and its relationship morbidity and mortality after acute myocardial infarction: Systematic overview. Arch Intern Med, 164, 1514-1518.
Rene Salazar, MD
Socioeconomic Status – SBS Clinical Teaching Pearls
Social and Behavioral Science Curriculum Theme
SOCIOECONOMIC STATUS
Definition: Socioeconomic Status (SES) is also referred to as social class. Comprised of 3 main elements: Income, Education, and Occupation. Education is the most robust predictor of morbidity and mortality.
Clinical Relevance:
b. People of lower SES have higher rates of morbidity and mortality.
o Areas of poverty have 50% higher mortality rates and geographical clustering of higher accidental injury, infant mortality, suicide, and lower birth weight (Yen & Kaplan, 1999).
c. SES indicators are significant predictors, accounting for up to 70%, of health status. Biomedical factors only account for 30%.
o Determinants of health: 30% Genetic predisposition, 40% Behavioral patterns, 10% Health care, 5% Environmental exposures, 15% social circumstances (McGinnis et al., 2002)
d. Why do people of lower SES have increased mortality and poorer health?
o Health care disparities based on SES are well documented. Lower SES individuals receive lower quality of care and have lower access to care.
o Financial factors: More likely to be uninsured, lower income
o Social factors: Less social support and resources, lower knowledge about prevention, clinical conditions, and treatments, lower level of safety and housing quality, greater severity and frequency of life stressors
o System and Community factors: Transportation difficulties, less exercise venues, lower access to healthy foods and medications
a. For individuals of low SES, long-term experiences with poor quality and access to health care can lead to: lower sense of control, self efficacy, optimism, likelihood to seek help, and mistrust in clinicians.
e. Ethnic minorities are up to 3 times as likely to live in poverty. We must caution not to use race as a proxy measure of SES - they are independent constructs. Collapsing race with SES can increase provider bias.
Clinical Pearls:
f. Be knowledgeable about the above barriers to equal health + health care based on SES. Know the provider’s role and the system’s role in addressing these barriers.
g. Improved provider-patient communication and proactive provision of care is needed for lower SES patients.
o Ask yourself: Has this patient had a history of difficult health care experiences? How can I facilitate a more positive provider interaction?
o Counteract lower health education by actively educating your low SES patients about health, prevention, clinical conditions, and treatments. Don’t assume they will not understand or do not want the information.
h. Treatment plan recommendations: Lower SES individuals often need integrated care, social resource referrals, and behavior monitoring. Utilize community health staff and multidisciplinary and preventive care teams in their care.
i. Provide consistent and equitable health care based on need and evidence-based guidelines. This approach will help to minimize health care disparities for lower SES individuals.
Key References/Resources
j. Lynch JW, Kaplan GA, Pamuk ER, Cohen RD, Heck KE, Balfour JL, & Yen IH. Income Inequality and Mortality in Metropolitan Areas of the United States. Am J Public Health. 1998: 88: 1074-1080.
k. Yen IH & Kaplan GA. Neighborhood Social Environment and Risk of Death: Multilevel Evidence from the Alameda County Study. Am J Epidemiol. 1999;149: 898-907
Jason Satterfield, PhD
Stress and Coping – SBS Clinical Teaching Pearls
Social and Behavioral Science Curriculum Theme
STRESS AND COPING
Definition and Key Terms:
• Stress: A negative emotional experience accompanied by predictable biochemical, physiological, cognitive, and behavioral changes that are directed either toward altering the stressful event (i.e. the stressor) or accommodating to its effects. Technically, a “stress response” refers to the physiological processes related to stress. “Stress process” includes the biological, cognitive, behavioral, and emotional changes related to stress.
• Stressor: A real or imagined aversive or threatening event or situation. Note that a stressor can be a negative event (e.g. loss of a job) or a positive event (e.g. birth of a new child). Stressors that are negative, uncontrollable, ambiguous, novel, central to life values, and chronic tend to be experienced as more stressful.
• Appraisal: When a stressor occurs, an individual makes two appraisals that determine whether or not there will be a stress response and, if so, how intense that stress response will be. A primary appraisal is made regarding the stressor – “Is this stressor something I need to worry about? Is it a threat? Does it matter?” The secondary appraisal is made to assess the individual’s coping resources – i.e. “Given this stressor, do I have enough energy/support/resources to cope with it adequately?” If a stressor is deemed very important and threatening (primary appraisal) and coping resources are seen as deficient (secondary appraisal), the stress response will most likely be large.
• Coping: Coping is simply the emotional, cognitive, and/or behavioral response one generates in response to a stressor. Effective coping will decrease the stress response and/or resolve the problem. Ineffective coping may intensify the stress. Coping is divided into two categories – problem-focused coping and emotion-focused coping. Problem-focused coping directly addresses the stressor – e.g. studying for an exam. Emotion-focused coping changes the emotional experience of the stressor but does nothing to change the situation – e.g. listening to music, surfing the web, distracting yourself to avoid a stressful situation. Oftentimes, a mixture of these two types of coping is optimal.
Clinical Relevance:
• How Stress Causes Disease.
o Direct physiological effects (through HPA Axis and sympathetic-adrenal-medullary)
o Changes in health-related behaviors like diet, exercise, smoking
o Changes in medical adherence and/or utilization (e.g. keeping appts)
• Stress has been tied to onset, duration, severity, and/or resolution of most diseases. Even if stress doesn’t have a direct biological effect, it may greatly amplify psychological suffering.
Clinical Pearls:
• Ask about stressors in 2 domains: occupational and social. Remember that stressors that are novel, ambiguous, threatening, and/or chronic have the greatest negative effects.
• Ask about appraisals: When asking patients about stress, remember to ask about their perceptions of the stressor and their perceptions about their coping resources. This helps predict the magnitude of the stress response and may identify areas for supportive interventions (e.g. correct information about risk, minimal required support).
• Ask about coping. It is important to ask about stressors and appraisals (i.e. perceptions) but that should be followed with “and how do you usually cope with stress? How effective has that been for you?” The goal is to identify adaptive habits to reinforce and maladaptive habits to change.
Key References/Resources:
Lazarus, R. S., & Folkman, S. (1984). Stress, Appraisal, and Coping. New York: Springer.
McEwen, B. S. (1998). Protective and damaging effects of stress mediators. NEJM, 338(3), 171-179.
-----------------------
[1] National Literacy Act of 1991. Pub. L. No. 102-73, 105 Stat. 333: (1991)
[2] Healthy People 2010. Document/HTML/Volume1/11HealthCom.htm.
[3] Kutner,M.,Greenberg,E.,Jin,Y.,and Paulsen,C.(2006).The Health Literacy of America’s Adults:Results From the 2003 National
Assessment of Adult Literacy(NCES2006–483).U.S.Department of Education.Washington,DC:National Center for Education
Statistics.
-----------------------
-----------------------
Key ideas to reinforce and/or elaborate:
• Ask about the patient’s beliefs about treatment. Your models of treatment may vary widely. Negotiate a common ground.
o “What treatment do you think will help you the most?”
o “Can we combine our two ideas?”
• Use the Transtheoretical model (Stages of Change): Discuss pros and cons of adherence. Help the patient feel more confident in the outcome of treatment and in their ability to follow through.
o “Have you thought about exercising more?”
o “What would you lose by exercising more?”
o “How confident are you that you would be able to exercise more?”
If good rapport exists, then ask about adherence (think of it as a mutual challenge to resolve):
o Normalize non-adherence – “This is really hard for most folks to stick with….”
o Phrase questions to make revelation easier – “When was the last time you missed a dose? About how many did you miss this week?”
o Give recent and limited time frame – Ask about adherence over the past few days or past week at most. Recall beyond one week is quite poor.
Ask about reasons for non-adherence AND reasons for adherence:
o “What made it difficult to take your blood pressure pills?”
o “You mentioned that you almost always remember to take your antidepressant; what helps you remember?”
o What mat
Goal Setting:
• It is important to find a goal that the patient can identify as important in improving their health.
o “What would be a goal you would like to have regarding your health?(e.g., lower blood pressure, lower sugars)”
• Often patients in this situation, realizing the need to lose significant amounts of weight, might suggest that they want to lose 100 lbs in the next two months. It is helpful to redefine the goal into what is doable. Examples of what you might say include:
o “That’s an ambitious goal, and I share your desire to get there. Can we set up a realistic short-term goal to get to en route to our eventual goal”
o “We should think together about a specific goal. What weight should we strive for by your next visit?
o “Maybe we can be flexible about this goal?”
• Goals can often be reached with the support of those involved in the
patient’s life.
o “How can your family help you reach this goal between now and the next visit?
Self Monitoring:
• Do you think you could keep a food diary for one week so that we can see the pattern of your eating?
• Do you think you could keep a log of your physical activity for one week?
• How hard would either of these tasks be to do?
• Is there anyone who can help you in keeping these logs?
Clinical Example: Smoking
Ask “Do you smoke?” at every visit even after they quit. Identify their smoking status in the chart.
Advise them to quit smoking at every visit. Be clear (“I think you should stop smoking now.”), strong (“Quitting is the single most important thing you can do for your health.”), and personal (“Your children won’t be exposed to toxins.).
Assess their readiness to quit by asking them if they want to quit. If they say no, find out about their pros/cons or barriers to quitting. Ask them to think of pros/cons of smoking. Have them rate the importance of quitting and their confidence that they can quit on a 1-10 scale. Discuss the scores.
Assist them with a plan if they’re ready to quit. If not ready to quit, assist them in moving forward in the stages of change (e.g. contemplation, use processes of change). Keep the conversation active. Keep the patient thinking about the behavior (e.g. keep a smoking diary, discuss with others who have quit, etc).
Make a quit date.
Arrange follow up if possible or speak with patient. Meet on or within one week of the quit date. Then meet at one month, two or three months then as needed, especially in the first year. (The 3 month cessation rate is 5% without follow up and 15% with follow up).
Give them information about quitting and self-help materials.
Nicotine replacement is recommended for those heavily addicted (smoke within 30 minutes of waking, smoke more than one pack per day, failed prior quit attempts).
Consider a smoking cessation referral.
Follow up with health provider if available in your setting.
If not ready to quit, assist them in moving forward in the stages of change (e.g. use processes of change above). Keep the conversation active. Keep the patient thinking about the behavior (e.g. keep a smoking diary, discuss with others who have quit, etc).
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.