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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Many more fires to fight and tails to chase yet
Multimorbidity: a huge challenge
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Kathryn Mott, Adelaide, Australia Senior Project Manager, University of South Australia
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The work by Russell et al in your latest edition resonated well with the experience in Australia in terms of chronic illness management and care by general practitioners (similar to Canadian family physicians). In conducting the evaluation of the Enhanced Primary Care Medicare Benefits Scheme (MBS) items 5 years ago, it was clear that most GPs were struggling with the concept and perceived major barriers to care planning. Many recognised the need for proactive approaches to care for people with chronic illness, especially those with multiple conditions and complex issues involved, however all found it difficult to fit this approach into their current practice. Australia has introduced a range of payments for GPs through the MBS, recognising one of the biggest barriers to care planning and chronic illness management was inadequate remuneration through normal payment for acute care. The reality is that no amount of money seems to have increased the uptake of these items over the past 5 years. In the end it seems it is time and attitude that stops care planning happening. GPs are still grappling with how to use these items effectively and remain somewhat suspicious of the value of producing written care plans. For many of us working in and around primary care service delivery, the answer has always been about emphasising the processes of care and the engagement with the patient as being what care planning is all about - not the written product at the end. But most GPs, and most other health professionals such as pharmacists and nurses, are still stuck in work patterns and systems that are built around acute incidents and isolated from each other. Newer graduates are learning about multidisciplinary team care around complex patients, but there is a large workforce that has rarely experienced this way of working. There are many unique challenges around the introduction and integration of new approaches to chronic illness management: * It has to be system driven - policy and programs have to enable such approaches to become reality. Barriers need to be removed. * It has to be profession driven - leadership from the professional bodies is critical. Opinion leaders need to embrace the new ways and actively promote them to their peers. * It has to be patient driven - expectations need to be expressed by patients about their acceptance of and demand for better chronic illness management. Most patients are capable and will participate given the chance. * It has to be practice driven - support can be provided to individual health providers and their teams to re-organise their appointment schedules, their staff mix and their understanding of other health providers and how to work better with them around patient care. Australia has done some positive work to address all of these challenges, but it is still not the case that people with chronic illness have comprehensive, proactive planning around their needs. GPs and others still are putting out fires and often chasing their tails. Many who are working hard to shift the culture and see bigger changes in attitudes and approaches will add banging your head against a brick wall to the list. Competing interests: None declared |
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Martin Fortin, Saguenay, Canada Professor, Département de médecine de famille, Université de Sherbrooke
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This study by Russel and colleagues is interesting in many ways. Nested into a clinical trial, this study helps understand what really happens when implementing an intervention. The phenomenological approach allows for a deep understanding of the experience of the physicians involved in the trial. What struck me is how difficult it is to modify the way family doctors are caring for patients with multiple chronic illnesses and how self-care is difficult to implement. The unenthused physician in this study helped identified important barriers to implementation of more patient-centered attitude and identification of shared goals. Seeing patient as the primary provider is far from being accepted by those physicians. This reminds us that improving care for chronic diseases will need a major change in culture. We have to trust the patients in their capacities of making changes in their life to improve their health. We have to trust the patients in their abilities to take care of themselves. We have to trust the patient and patients also have to trust their doctors about their ability and willingness to help them achieve their goals. The “this-is-not-my-job” way of acting is simply not acceptable from a doctor. To this attitude, we could answer: “This is precisely your job and your art, doctor!” Although the number of patients involved in this qualitative study was low compared with the doctors, it was nonetheless important to listen to them and to learn from them. Especially amusing to hear them say they barely noticed any change! It puts some doubt on the real application of the care plan and the identification of shared goals. Did the intervention really occur the same way for all patients? Maybe not. The challenge of caring for patients with multiple chronic illnesses is huge. This study is a confirmation for that. Patient-centered care, shared decision making, shared goals, improving selfcare, focusing on prevention and lifestyle modification, psychological and social assessment and support, review of medication and community integration are all part of a puzzle in which doctors, nurses, specialists, other professionals, caregivers and patients themselves are actors having to learn to work together. Competing interests: None declared |
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