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Table of Contents
EDITORIAL
Year : 2017  |  Volume : 21  |  Issue : 3  |  Page : 365-366

Responsible patient-centered care


1 Department of Endocrinology, Bharti Hospital, Karnal, Haryana, India
2 Department of Endocrinology, Excel Hospitals, Guwahati, Assam, India
3 CEO, Chellaram Diabetes Institute, Pune, Maharashtra, India

Date of Web Publication2-May-2017

Correspondence Address:
Sanjay Kalra
Department of Endocrinology, Bharti Hospital, Karnal, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijem.IJEM_543_16

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How to cite this article:
Kalra S, Baruah MP, Unnikrishnan A G. Responsible patient-centered care. Indian J Endocr Metab 2017;21:365-6

How to cite this URL:
Kalra S, Baruah MP, Unnikrishnan A G. Responsible patient-centered care. Indian J Endocr Metab [serial online] 2017 [cited 2017 Jul 23];21:365-6. Available from: http://www.ijem.in/text.asp?2017/21/3/365/205492

Patient-centered care (PCC), an integral part of the diabetes care lexicon, is defined as providing care that is respectful of and responsive to individual patient preferences, needs and values and ensuring that patient values guide all clinical decisions.[1] While this definition has survived the test of time, it raises many queries as well.[2] Does the treating physician abdicate all decision-making to the patient, who then decides targets, strategies, and tools of treatment? Does the physician accept patient-centered preference and values, even if they compromise with biomedical efficacy? More importantly, does the patient-centric physician respect and respond to all patient demands in the affirmative, even if they affect his or her safety and well-being?

Such questions create an ethical dilemma, especially for students of medicine, who may read the definition of PCC in a literal sense. How should a patient-centered physician behave? What are his responsibilities and rights? As a corollary, what are the rights and responsibilities of a person with diabetes who seeks care from a patient-centered physician or a patient-centered health-care system?

We have previously described the attributes of a good diabetes care professional as an acronym CARES (confident competence, authentic accessibility. reciprocal respect, expressive empathy, and straightforward simplicity).[3] In this editorial, we suggest the concept of responsible patient-centered care (RPCC), delivered by a responsible patient-centered physician (RPCP), and health-care system.

RPCC is that in which the physician or health-care team take on the responsibility of ensuring that the person with diabetes is offered all relevant information, in an understandable manner, so that he or she can take part in a shared decision-making process, which offers the potential for achieving optimal therapeutic outcomes, without ignoring his or her biopsychosocial context. RPCC also implies that the physician or health-care team fulfill their duty in a responsible manner, considering the implications of any decision on all stakeholders [Table 1]. RPCC encourages shared responsibility between the members of diabetes care team, including medical and nursing personnel, and family members. RPCC extends to health policy makers, to provide diabetes-friendly health-care facilities, and to civil society, to create a healthy social environment.[4],[5] This approach in embedded in national guidelines from India.[6],[7]
Table 1: Responsibility: Domains

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To describe RPCC, we suggest a list of ten R's, which indicate the core values of this health-care philosophy [Table 2].
Table 2: The 10 Rs of responsible patient-centered care

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  1. Respect: RPCC providers should be sensitive toward the psychosocial reality and personal or sociocultural beliefs of the person with diabetes and his or her family. This respect should be conveyed through both verbal communication and nonverbal gestures
  2. Responsiveness: The RPCC team should respond to cues offered by the person with diabetes, which may indicate his or her attitudes, wishes, or needs. Motivational interviewing techniques, such as WATER,[8] are an effective way of doing so
  3. Restrain from self-harm: In a life-threatening, organ-threatening or limb-threatening clinical situation, (irrational) beliefs may place the person with diabetes at the risk of harm. For example, a person with oral drug inadequacy may resist insulin initiation. This can have both short-term (e.g., worsening of a foot ulcer, leading to amputation) and long-term impact (e.g., poor control leading to a stroke). The RPCC team should counsel the individual and restrain him or her from self-harm
  4. Realism or realistic approach: RPCC should include psychosocial assessment and addressal in its her ambit. This includes getting a realistic idea of the patient's social background, including availability of financial and emotional support. This will help in designing a management plan which can be adhered to within available resources
  5. Resource husbandry: The RPCP should be able to add to, or work within, available resources, by matching physiological needs with pharmacological knowledge and psycho-socio-financial understanding. In a pay from pocket market, for example, the RPCP may decide to prescribe an expensive, but extremely effective, antibiotic to a patient with limb-threatening disease. In the interest of cost containment, however, he or she may discontinue statins or multivitamins, or postpone a due vaccination, for a finite period
  6. Relevance: Relevance, or prioritization, is an art that the RPCP must master. Relevance is relevant in deciding what information is to be shared in diabetes education, what diagnostic modalities are to be used, and what therapeutic options should be offered. A person with blurring of vision should be offered care relevant to his symptom while another with an incidentaloma detected on an imaging scan should be approached differently
  7. Reach out: The RPCP should not hesitate to reach out to others for support or guidance. “Others” may include medical and health professionals of different specialties, lay educators, family member, community or religious leaders, and policy maker. A “metabolic alliance,” committed to managing diabetes, while keeping the person with diabetes at center, can work wonders
  8. Restrain from other harm: The person with diabetes does not live in isolation but is part of a larger society. Responsibility to the patient does not mean that the physician can shirk his or her duty to society. A patient with recurrent hypoglycemia, who may put other members of society at risk by virtue of his occupation; for example, professional driving, should be counseled to change work. If required, the RPCP should notify the authorities. A similar situation may be encountered if a patient contracts a disease such as HIV. In such cases, the RPCP should follow local rules and regulations
  9. Revision: RPCC is a dynamic and ongoing process. Frequent assessments and audits should be made, with mid-course correction being done whenever suboptimal outcomes are noticed, or anticipated
  10. Reflection: PCC is a philosophy, a way of thinking and practice and a style of working. It is an integral part of diabetes care and should be embedded in every communication and action. The astute RPCP should reflect on what PCC conveys, and how this concept can be implemented in the best way possible. This is an ongoing process; a task that continues throughout one's professional career.


To our readers, we say: We hope you get better and better at RPCC. We hope we do, too.

 
   References Top

1.
Committee on Quality of Health Care in America Crossing the Quality Chasm: Institute of Medicine (U.S.). A New Health System for the 21st Century. Washington, DC: The National Academies Press; 2001.  Back to cited text no. 1
    
2.
Kalra S, Megallaa MH, Jawad F. Patient-centered care in diabetology: From eminence-based, to evidence-based, to end user-based medicine. Indian J Endocrinol Metab 2012;16:871-2.  Back to cited text no. 2
    
3.
Kalra S, Kalra B. A good diabetes Counsellor 'Cares': Soft skills in diabetes counselling. Internet J Health 2010;11:1.  Back to cited text no. 3
    
4.
Kalra S, John M, Unnikrishnan AG, Sahay R, Baruah MP, Bantwal G. Children with diabetes friendly services: A blueprint. J Soc Health Diabetes 2013;1:75.  Back to cited text no. 4
  [Full text]  
5.
Wangnoo SK, Maji D, Das AK, Rao PV, Moses A, Sethi B, et al. Barriers and solutions to diabetes management: An Indian perspective. Indian J Endocrinol Metab 2013;17:594-601.  Back to cited text no. 5
    
6.
Kalra S, Sridhar GR, Balhara YP, Sahay RK, Bantwal G, Baruah MP, et al. National recommendations: Psychosocial management of diabetes in India. Indian J Endocrinol Metab 2013;17:376-95.  Back to cited text no. 6
    
7.
Kalra S, Baruah MP, Ranabir S, Singh NB, Choudhury AB, Sutradhar S, et al. Guidelines for ethno-centric psychosocial management of diabetes mellitus in India: The North East consensus group statement. J Soc Health Diabetes 2013;1:9.  Back to cited text no. 7
    
8.
Kalra S, Kalra B, Batra P. Patient motivation for insulin/injectable therapy: The Karnal model. Int J Clin Cases Investig 2010;1:11-5.  Back to cited text no. 8
    



 
 
    Tables

  [Table 1], [Table 2]


This article has been cited by
1 Diabetes care: Evolution of philosophy
Sanjay Kalra,ManashP Baruah,Bharti Kalra
Indian Journal of Endocrinology and Metabolism. 2017; 21(4): 495
[Pubmed] | [DOI]



 

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