Relationship Centered Care (RCC)

Patient-physician relationship is an important aspect of medical practice. We see hundreds of patients, and looking back every one will admit that each individual is different. Even with the same disease different people present in a different way, they react differently and they respond to treatment differently. Thus each individual need different approach or they need “special care”. Spending some time with the patient, interacting with him on his concerns and suffering will help the physician choose an individually tailored treatment rather than prescribing the same to all patients with the same disease.

In an era of technological advance it is often accused that the doctor is communicating more with machines than with his patients. The younger generation more often employs technology rather than depending on clinical skills. Medical complexity, interpersonal challenges and administrative burden have been cited as the chief barriers to communication with the patients. This definitely compromises the quality of care. Many efforts to change the behaviour of physicians failed. More over as a result of technology based failures and distractions, many patients have concerns and their expectations are often unmet.

In relationship centered care patients and physicians work together in pursuing shared goals in health care with attention to both illness and personal experiences. Here the both patients and physicians have responsibilities, are willing to negotiate and gain something through their relationship and encounters. It is often better to know the patient and his environment before administering the care. The relationship centered approach involves physician understanding the patient’s perspectives, being responsive to the needs of the patient and sharing treatment relevant power with patient and relatives.

We should always remember that patient-physician relationship is the most consistently reported and powerful determinant of physician satisfaction.

Critical Thinking in Clinical Medicine

 

One of the most important attributes of a successful clinician is the ability to think critically in patient care situations. Critical Thinking in clinical Practice is to enhance skills in making well-informed, ethical decisions. Making such decisions is not easy. Decisions are made in

uncertain, changing environments with time pressures. Decisions are influenced by a variety of fallacies and biases that we can learn how to avoid. Critical thinking values, knowledge, and skills, therefore, are integral to evidence-based practice. It is also important to recognize

common pitfalls in clinical reasoning as well as strategies for avoiding them. These emphasize the importance of recognizing ignorance as well as knowledge and the vital role of criticism in discovering how to make better decisions. Critical thinking is a dynamic, purposeful, analytic process that results in reasoned decisions and judgments. To think well is to impose discipline and restraint on our thinking, by means of intellectual standards.

This process¹ incorporates the following competencies:

• Interpretation: This is the ability to understand and identify problems.
• Analysis: This is the ability to examine, organize, classify, categorize, differentiate, and prioritize variables.
• Evaluation: This is the ability to assess the credibility, significance, and applicability of sources of information necessary to support conclusions.
• Inference: This is the ability to formulate hypotheses or draw conclusions based on the evidence.
• Explanation: This refers to the ability to explain the assumptions that lead to the conclusions reached.
• Self-regulation: This indicates the ability for self examination and self-correction.

The critical thinker is characterized by open mindedness, flexibility,rationality,inquisitiveness,

intuitiveness, and reflection. The trend nationwide is to track and evaluate the critical thinking process throughout the curriculum. The development of critical thinking, the ability to solve problems by assessing evidence using valid inferences, abstractions, and generalizations, is one of the global goals advocated by most medical schools². Many institutions have initiated evaluation of their students for critical interactive thinking skills. This was practiced in nursing schools of the west since 1960. During admission to the nursing course students undergo pre and post entrance evaluation programme to ascertain and stimulate critical thinking skills. Most of the reputed medical schools also practice this. I feel that this should be included in the curriculum of Indian Medical schools. However our students either fail to acquire this skill or are not fully aware of the benefits it impart towards development of good clinical skill. Teachers should take special interest in creating critical thinking skill among their students. Clinical teaching can be modified in such a way that interpretation and analysis are based, to an extent, on critical thinking.

The cognitive skills tested by the California Critical Thinking Skills Test (CCTST) are interpretation, analysis, evaluation, explanation, and inference. The test was developed to assess the critical thinking skills of college students. The test’s content validity and experimental validation were based on four experiments conducted at California State University, Fullerton. Further evaluation of this instrument, including factors predictive of critical thinking skills; effect of ethnicity, and critical thinking esteem (one’s view of one’s critical thinking abilities); and interpretation of group norms and sub scores have also accomplished. The development of critical thinking, the ability to solve problems by assessing evidence using valid inferences, abstractions, and generalizations, is one of the global goals advocated by most medical schools. This study determined changes in critical thinking skills between entry and near the end of the third year of medical school, assessed the predictive ability of a test of critical thinking skills, and assessed the concurrent validity of clerkship components and final grade. The Watson–Glaser Critical Thinking Assessment (WGCTA) was administered to one class of students at entry to medical school and near the end of year 3. Performance data for those students who completed their clinical clerkships on schedule were also recorded. Critical thinking improved modestly but significantly from entry to medical school to near the end of year 3.Strengths in critical thinking skills have been noted in institutions where faculty participate in discussions about critical thinking and impose curricular changes to enhance students’ critical thinking skills. Five methods3 are used: 1) observation of students in practice; 2) questions for critical thinking, including Socratic questioning; 3) conferences; 4) problem-solving strategies; and 5) written assignments. These methods provide a means of evaluating students’ critical thinking within the context of clinical practice. Students bring with them critical thinking skills on entering university courses and will necessarily have a bearing on how they manage their studies and gain new knowledge.³ The intellectual roots of critical thinking are as ancient as the teaching practice and vision of Socrates,who discovered a method of probing questioning that people could not rationally justify their confident claims to knowledge. Socratic questioning is a simple yet strong method for exploring ideas or statements in depth and breadth. It is applicable in all courses and an essential tool of all teachers of thinking. In simplest form, it involves:

a) Selection of a question or issue of interest.

b) Production and examination of a Central Statement from some source or produced by a student in response to the question or issue.

c) Clarification of the statement and its relationship to the question or issue.

d) Listing and critical examination of support, reasons, evidence, and assumptions related to the central statement.

e) Exploration of the origin or source of the statement.

f) Developing and critically examining the implications and consequences of the statement.

g) Seeking and fairly examining conflicting views (alternative points of view).

The basic questions of Socrates can now be much more powerfully and focally framed and used. In every domain of human thought, and within every use of reasoning within any domain, it is now possible to question:

• Ends and objectives,
• The status and wording of questions,
• The sources of information and fact,
• The method and quality of information collection,
• The mode of judgment and reasoning used,
• The concepts that make that reasoning possible,
• The assumptions that underlie concepts in use,
• The implications that follow from their use.
• The point of view or frame of reference within which reasoning takes place.

Conclusion: Critical thinking is not just thinking, but thinking which entails self-improvement. This improvement comes from skill in using standards by which one appropriately assesses thinking. Or in simple terms it is self-improvement (in thinking) through standards (that assess thinking). Day to day practice needs a lot of thinking, as decisions are taken at bedside in a limited time frame. There ought to be mistakes which can invite disaster. So every physician should have one or more alternate diagnoses apart from the best possible diagnosis. Establishing the best possible decision from a group of probable alternatives needs critical thinking. Here the physician needs to frame few questions such as “why this diagnosis” and “why can’t it be some thing else” etc. Questions thus framed may be based on Socratic questioning. Then these questions are answered logically to gain the advantage of reaching the correct decision.

Asthma & Psychological Link

Introduction

Asthma is a chronic and episodic illness causing obstruction of air passages making it difficult for a person to breathe normally. For a normal individual breathing is a natural effortless exercise done involuntarily. But for an asthma patient, normal breathing is itself a laborious effort, reducing the quality of life. What is the cause of asthma? Is it a pathological condition or a psychosomatic illness? This is being debated for a long time.

Prevalence of asthma is between 5-10%.Certain Indian cities like Delhi and Jaipur reported a higher prevalence ranging between 24-38% among school children. Asthma usually starts in childhood. It is widely believed that 50% of asthmatic develops their first symptom before the age of 6 years. There is genetic predisposition; even though a single gene responsible for asthma is not so far identified. Probably it is multifactorial, genetic        susceptibility and environmental factors contribute to asthma.

Mechanism

As per the present scientific knowledge asthma is a medical condition. The main inciting cause is environmental allergens leading on to a cascade of cellular activity resulting in narrowing of airways. The pathology in asthma sets off in the following manner.

• The muscles of the airways constrict.
• Mucus membrane lining the airways swells.
• Mucus collects in the airways further blocking the air flow.

These subsequently lead to breathlessness, wheezing and coughing. Some of the main triggers are house dust, pollen, fungi, insects, animal danders, food, sudden change in climate and certain chemicals.

However, according to traditional viewpoint, asthma is primarily a somatoform disease with psychological variables. The widely supported belief is that powerful emotions like anger, worry and fear trigger asthmatic attacks. This is not surprising since we all experience a change in breathing pattern whenever we are under a high state of excitement and stress. The other significant reasons believed to trigger asthma are anxiety and depression disorders.

Asthma was one of the “Holy Seven” illnesses thought to be psychosomatic. Research suggests that psychiatric forces may affect the clinical expression of asthma in several ways: altered awareness of airway resistance, suggestibility of airway constriction, comorbidity with panic disorder and depression.

The true picture may be somewhere in between purely physiological causes and psychological triggers. Inputs provided by the sufferer to the health care provider will play a vital role in identifying the true cause. Even though asthma itself is an organic disease there are a few variants where the clinical picture is asthma mimic. For example anxiety is a psychological problem and in its extreme it increases the respiratory rate to an extent that it resembles asthma. Co existing anxiety or panic disorder probably worsens the course of asthma. As much as 30% of persons with asthma meet criteria for panic disorder or anxiety hyperventilation. Panic disorder appears to be underestimated by doctors and its symptoms may be misunderstood as that of asthma worsening. An extremely high level of anxiety predicts increased rates of hospitalization and asthma associated deaths. It can go to an extreme of hysterical reaction again mimicking asthma.

Depression has a meaningful and negative effect on the course of asthma. Depression can lead on to breathlessness, but at the same time being chronic illness asthma itself can precipitate depression. Depressed patients tend to manage their asthma poorly.

 Another variant noticed among young female patients is the vocal cord dysfunction (VCD) where the patient present with asthma and wheezing. It is not due to bronchospasm but due to functional closure of vocal cord during inspiration. The abnormal laryngeal sound resembles wheezing or stridor. This has strong psychological association. Some VCD patient may have a comorbid psychiatric illness and traumatic childhood history that contribute to the symptoms and interfere with their care.

Conclusion:

Asthma is a chronic disease affecting 5-10% of population all over the world. This is an organic disease with definite patho-physiological changes in the body. However it can be precipitated or worsened by many psychological factors that the individual is facing even to an extent that asthma sometimes is considered as a psychosomatic illness. More over there are psychological conditions or situations where the respiration is affected and many a time this situation resembles asthma (Asthma mimics).So it is important that psychological triggers may be properly identified and corrected and at the same time asthma mimics should be segregated and considered as purely psychological illnesses and managed accordingly. Until such time medical advances throw more light on the causes of asthma, management focus will be on psychological intervention, behavioral treatment and conventional medication.

Dr C Ravindran MD,DTCD,MBA

Former Principal

Govt.Medical College, Kozhikode

My Almamater

Govt. Medical College, Calicut