What are the determinants of how someone experience a symptom?
- Sensation (nociceptive, neuropathic)
- Perception (alertness/arousal, distraction, hallucination)
- Mood
- Motivation
- Expectation
What are some problems with the biomedical model of disease?
- A lot of symptoms don’t have a pathological basis
- Applying the biomedical model in these cases can lead to harm
- Outcomes depend on many factors external to correct diagnosis and treatment
What is DCTA?
Direct to consumer advertising of prescription drugs
Distinguish between symptom and disease
- Symptoms are subjective & disease is objective
- Both describe either perceived or observable abnormalities in the body
What distinguishes malingering, factitious and somatoform MUPS?
- If symptoms are intentionally produced
- If there is a conscious reason for symptoms
What are the four clusters of MUPS?
- Gastrointestinal
- Musculoskeletal
- Cardiopulmonary
- Fatigue/general
What are the four basic strategies for decision making?
- Pattern recognition
- Hypothetico-deductive
- Algorithms/branching schema
- Unfiltered data collection
What are the 3 types of hypothetico-deductive thinking?
- Deduction (general to specific) hypothesis > observe > confirm
- Induction (specific to generla) observe > pattern > hypothesis
- Seduction/abdication (Defer to other)
Problem > ask someone else > fact
What are the 2 systems of thinking?
System 1 - rapid, unconscious, retrieval
System 2 - slow, conscious, deliberate
What is heuristic-analytic thinking?
- System 1 dominant
- System 2 monitors and can step in
- Need to slow down to reduce errors
What is the exemplar for system thinking?
- System 1 first
- No solution?
- System 2 steps in
- Sequential
- Reduce error by gaining knowledge and structured reflection
What are some non-cognitive factors that affect thinking? `
- Personal (knowledge, experience, beliefs)
- Affective (mood, relationship, atmosphere)
- Evidence (meta analyses, guidelines)
- Peers
- Patients
- Environment (setting, tools, time)
- Political/society
- Legal
- Desired outcome (implications)
What are the 6 domains you need to consider when evaluating a patient’s adherence?
D emographics I nstitutional P hysician related T echnological C ognitive S ocio emotional
Define non-adherence
When patients do not adopt behaviours or treatments that their providers recommend
Why is non-adherence important?
- Treatment efficacy
- Cost (and opportunity cost) of wasted medicines
- Need to be able to differentiate between non-adherent and non-responsive
Anything that requires increased ___ will reduce adherence
Effort
What is an example of creative non adherence?
- Splitting pills to extend dose
- Pill sharing in families
- Supplementing treatments with other treatments
- Double dosing (halve the time)
What are some physician based interventions for improving adherence?
- Listen to patient, get them to repeat instructions back
- Simple prescriptions
- Written instructions
- Pill containers and reminders
- Call for missed appointments
- Take lifestyle into account
- Emphasise importance of adherence
- Acknowledge patient efforts
- Involve spouse or partner
- Ascertain worries and expectations
- Probe for barriers
- Share decision making
What are some ways of modifying institutional factors to improve adherence?
- Telephone or mail based reminders
- Reduce wait times for appointments
- Incentives (complex), fades once removed
What are the 3 subtypes of psychosocial factors important for adherence?
- Psychosocial characteristics
- Social network factors
- Cognitive factors (e.g. beliefs about medication, treatment efficacy)
What makes challenging interactions bad?
- Takes up time/resources
- Emotionally draining
- Contributes to stress/anxiety in doctors
- Affects healthcare decisions
- Makes mistakes
- Encourages doctor shopping
What are the four elements that influence a challenging interaction?
- Patient
- Doctor
- Illness
- System
What is the BATHE technique for challenging interactions?
- Background - what is going on in your life?
- Affect - what do you feel about that?
- Troubles - what about this situation troubles you the most?
- Handling - how are you handling this?
- Empathy - that must be very difficult for you
What are the 3 domains you need to be aware of in a challenging interaction?
- Boundaries
- Agendas
- Emotions
