Improving health care for veterans has become a matter of national attention and has gained increasing attention from the medical community. With the current surge of veterans reintegrating into civilian society it is critical to improve the training of the next cadre of providers who will provide care for our veterans. It is widely known that veterans receive care in all aspects of the health system, thus providers in veteran focused care facilities, military health serves and civilian locals must be aware of the unique needs of veterans. It is perhaps even more important to educate civilian providers who may be unfamiliar with the unique physical, mental and emotional needs related to military service. Course Audience - all health professions learners, example: - medical students, resident physicians, dental students, - nursing students, advanced practice nurses, - social work, pharmacy student as graduate level learners - as well as any and all health professionals interested in veteran-centered care What You Will Learn: This course will provide learners the opportunity to engage with material to facilitate their understanding of the origins of Academic Medical Centers and Veterans Administration affiliations, recognize and manage the influence of bias, class, and power on the clinical encounter and self-reflect on their biases that particularly affect U.S. military veterans. This course also features several video clips from the acclaimed documentary, Where Soldiers Come From, directed by Heather Courtney. The views expressed in this course are those of the authors and do not necessarily reflect the position or the policy of the Department of Veterans Affairs or the U.S. government.
03.01 - Interpersonal Approaches to Addressing Veteran Health Concerns
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From the course by University of Michigan
Service Transformed: Lessons in U.S. Veteran Centered Care
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From the lesson
Unit 3
Unit 3 outlines the fundamental principles of patient-centeredness and cultural competence in health care, provide tools to develop self-awareness of individual assumptions, stereotypes and biases that influence the medical encounter and deliver activities that help learners acknowledge the importance of patients’ values, culture, and beliefs in improving health care.
Meet the Instructors
Monica Lypson, M.D., M.H.P.E.Associate Chief of Staff for Education, Ann Arbor Veterans Affairs Healthcare System and Professor of Internal Medicine and Learning Health Sciences
University of Michigan Medical School
Paula Ross, Ph.D.Director, Advancing Scholarship and Medical Sociologist
Office of Medical Student Education
Hi, hello.
We're here for Unit 3 of Service Transformed, Lessons in U.S.
Veteran Centered Care.
And this unit we're going to focus on interpersonal approaches to veteran
health concerns.
We really want to develop your awareness and interest in focusing on the principles
of patient centered care, as well as cultural and military competence.
And acknowledging the importance of patient wishes, cultures,
and beliefs, but also having an awareness of your own biases.
Segment one, we're going to focus on patient centeredness in particular,
and as we think about this
there's a clear definition about what patient centered care really is.
Part of the definition it's a better understanding of the personhood
of the patient.
It appears to be a more humane and
respectful way of including patients in the interview process.
One might as isn't that how care has always been developed?
But I think it's a new awareness over the last couple of decades that in fact health
professionals really need to focus on patient's interests, patient's concerns,
and really try to figure out ways to illicit that information
to actually engage in a partnership that improves clinical outcomes.
There are clear dimensions of patient centered care,
you see these in this pie graph here.
And as we talked about a few minutes ago, you really want to focus on communication,
what kind of emotional support the patient need,
and how are you going to coordinate care over the long hall.
And this is true no matter what the problem is,
or who the help professional is interacting with the patient.
If you let think about what kind of communications skills
that you will need that are patient centered.
It's a set of behaviors and skills that promote the relationship,
in which patients are actively participate as partners,
in the management and the making of decisions.
Now, that doesn't mean a patient might say, Doc,
I want you to really focus on this aspect.
It might say nutritionist.
I'm really interested in this aspect of my care.
It might be that I really haven't enriching engaged relationship
with my retail pharmacist, and it is the retail pharmacist that really
understands me because they see me as a person and not necessarily as a patient.
In this segment, we're going to see several videos that really help identify
and review the conceptual framework of what patient centered care really is, so
we hope these videos give you a flavor about how you might enact those in your
day to day practice as a health care professional.
There's a video that is developed by the University of Michigan that really focuses
on our cardiovascular center where it shows how we can do patient centered and
family centered rounds while a patient is in the hospital.
Here's a nice definition and video that covers how patient centered
care is enacted within the Veterans Healthcare Administration.
It also gives you some background on how veteran perspective
are brought into the picture.
>> When this suite was designed, first and foremost on our minds was trying to create
an environment which was, which catered to patient privacy.
Patient's love coming here, as you can see it's a very luxuriously appointed room,
they love the patient privacy and they love the warm environment,
they love the soothing wall murals, and they love the kind of very
personalized care that they get, there's no feeling of they're just a number.
They get really very personalized care in a very comfortable environment,
a very private environment.
>> Having the focus on patients centered care really allows you to be humanistic,
and to realize that this is another human being you're taking care of.
And to relate to them.
So, not only are you helping demystify this health care system for
these patients, these veterans.
You also are finding healing.
Because you relate to them as a human being.
And you, yourself, get satisfaction.
From what you're doing because you deal with the whole individual.
You're dealing with their caregivers and helping them be empowered.
And then you have your staff rallying around you to provide you that support.
>> If it wasn't for
the acupuncture program that the VA is offering, I would be on medication.
And my quality of life would be greatly diminished.
And the side effects of the medication would be affecting me by now.
>> Personally, I'm a breast cancer patient.
I'm a two year survivor as of April.
To me, it's very personal, and I'm very proud of what we can offer women here.
>> Every individual in this country who's put on the uniform and
bore the stress of being a military person serving their country,
they deserve everything that we can give them.
To bring them back to their wholeness and their wellness again.
>> For staff, they're just starting their journey in VA.
They can use the model for the proactive components for
personalized proactive health.
If we were to look at that wheel and start with practices such as the importance of
sleep, the importance of wellness, the importance of spirituality, surroundings,
healing environments, interactions between staff and patients.
>> Bobby, we want you to be physically well.
We want to be able to help you in the other aspects of your life,
emotionally and spiritually.
And so if we can find an easy tool I give you a cell phone and
that helps you with that.
To me, that seems like a no brainer.
>> I've been a communication widow for at least five years,
as far as the telephone is concerned, and when I got the telephone, one of the first
person I called was my two daughters, and let them know that I had a telephone, and
now we can communicate now, and make up for lost times.
>> The way our patients centered care steering committee is designed
is that it's around the components of patient centered care.
What's key about the steering committee is the interdisciplinary staff.
We have staff that represent unions.
We have staff that represent the front line.
We have leadership teams.
We have veterans.
We capture all of the perspectives at this one committee.
And focus on these proactive components that are very important to veterans.
>> And there's yet another video on how you might define patient centered care.
After you watched those videos, now you want to step back and
figure out how you might enact those communication skills it really helps
you as the practitioner understand, and how to deliver important
care that is consistent with the patient's values and needs.
It also provides the patient with the opportunity for input and
active participation.
We are here talking about a veteran-centered approach, but
it really is those same principles of patient centered care,
really focused in a special way.
Really trying to understand what veterans bring to the healthcare environment.
And it really recognizes their background,
how they can access services, and how they might prioritize patient needs.
Again, these principles are needed, whether it's a veteran or a patient,
but veteran centered approach really gives you this idea that you really want to
take into account the veteran and their experience.
Again, this really allows you the ability to
understand the psychosocial context in which a patient has an illness or
in fact, a person experiences their health care episodes.
And then again it involves the patient and the discussion.
So here we're going to talk and see a video that really gives you some
excellent tips on how you might go about the patient centered medical interview.
And you might see that many examples, when you talk about patient centered
communications that really focus on the physician patient relationship,
but these tips that are seen in this video really cross all health professions.
And really gives you a some tips and some key suggestions about how you might
approach a patient in a very patient centered or veteran centered way.
Dr. Saul Weiner is an expert at thinking about
the patient context as it relates to their care.
He is a vice provost at the University of Illinois in Chicago
as well as a practicing veteran affairs physician and
is an internist and pediatrician.
>> Hello, everybody.
My name is Saul Weiner.
I'm a physician at Jesse Brown VA Medical Center in Chicago.
I'm also a faculty member at the University of Illinois at Chicago.
I have been practicing at VA facility for a little over a decade at this point.
And one of the things I noticed a long time ago, actually going back into
the 1990s, was that physicians, residents, medical students were getting better and
better at sort of following guidelines, following protocols.
Practicing what people refer to as evidence based medicine.
But with a narrow focus on the biomedical aspects of care.
A resident would typically come out and present a patient to me.
And they would really have the science right.
They would know the treatment guidelines.
If a person had diabetes or hypertension.
They would know what the next medicine is to add.
But oftentimes I felt there was something missing.
I would ask them a little bit about why the patient had lost control of their
diabetes, of their hypertension?
And I would get a bit of a blank look.
They hadn't asked.
And I often found that when I went back and asked the patient, gosh, Mr.
Jones, what happened to your diabetes.
You were doing so great, and now your hemoglobin A1C has shot way up.
What's going on?
And often, a story would come out.
I would find that they had competing responsibilities.
They may have gotten a job that put them to the night shift.
It may have been that there is a member of their family who's become ill and
now they're taking care of that person.
It could be that the medication they're taking is no longer covered, or
that they've been switched to a drug that's a non VA formula medication.
And they can't afford it.
The list goes on and on.
But often I found that there was something going on in their life,
something had changed.
And if that something were not identified,
simply going up on a medicine that they're taking really doesn't do the trick.
And, so this really led me to the concept of what I came to call contextual error.
We talk a lot about medical error.
You probably learned about that.
A medical error can be giving somebody the wrong medication for a condition, or
wrong dose of a medication.
In surgery, it could even be amputating the wrong limb, but
a contextual error is really where the science is right,
the biomedical part of it is right, but the care itself isn't right for
that individual because of something that is going on in their life.
That has not been identified and address.
Ask veterans about their service.
Any time you see a patient, ask them the question.
Tell me a little bit about where you served, when you served, and
if there's time, a little bit about what that was like.
The extent to which you ask about it is variable.
It depends on the nature of the interaction.
If you're taking care of an inpatient,
you may ask about it during the course of the hospitalization.
You can see how the person reacts, but I found it general
that even the most taciturn veterans will open up when you ask about their service.
It's a far more significant thing to do than just thanking someone for
their service.
And it's often a window into their life.
And I think that the other part of it, of course, is that when
patients come to the VA, they're not just patients, they're also veterans.
One of the things I see at my VA facility, and I've seen it at many others,
is that the patients comes there because it's also a kind of gathering place.
You'll never see people going to a hospital to hang out, but
at a VA facility you'll actually find that veterans go there to see each other.
It's their place, and that creates a very unique environment.
And I think if you're interested in caring for people in context,
the VA health care system is an ideal place to do that.
>> One of the things that one also wants to take into account when you say
that you're focusing on a patient, in a very patient centered way,
is also an aspect of that is cultural competence.
In fact, the two are not mutually exclusive as you might see here in
this picture, but if you look carefully at this diagram what you'll find is that
there's a large amount of overlap on what one might define as cultural competence,
or cultural humility as well as what one might define as being patient centered.
So, some of this focuses on you the health professional, so
we talked a little bit in unit two about your own biases and
assumptions what do you bring to the health care encounter, but
also it talks about understanding the patient in a very biopsychosocial
model that allows you to explore the patient's beliefs and values.
It allows you to help build rapport and trust.
When you don't know something it's a great opportunity to ask so that the patient can
help educate you on how to best tailor an approach to their care.
So if we want to look a little bit closer at a definition of cultural competence,
culture refers to the entire integration into the patterns of human behavior.
It might be our customs, our language, our social networks, etc.
And competence is really an array of abilities over a multidimensional time and
dynamic.
So we just talked about cultural competent.
What I hope to impart on you is that once you understand some
of the principles behind what it means to be cultural competent, I hope you don't
say check I'm done, I'm competent, I can move onto the next thing in my career.
In fact, cultural competency is part of a continuum.
And the way I like to think about it is the continuum of cultural humility,
it's really a life long process, self reflection, and self critique,
sometimes that mirrored, and you get feed back about how well you're doing, and
what things you need to improve on.
It's not really this idea that you can master someone elses different beliefs and
behavior, but it does give you the ability to really understand and
grow overtime about how you can interact with others.
And hopefully, have them open up to you, to tell you about this information,
really allows you to develop a respectful partnership between patients, and
it is how you actually demonstrate patient centered communication.
I think when you talk to all health care professionals that the reason they
went into medicine is really for this idea of what a transformative relationship is.
And it is the skill set of using both cultural humility along with the skills
that you gain for practicing and enriching your patients centered communication that
really allows you to move to this idea of what a transformative relationship is.
It allows you to engage in the process of mutual self discovery.
It allows you to overcome barriers in resistance, both on the part of the health
care provider, as well as the patient in terms of what makes sense and
what makes the best potential care outcome that one can have.
And its really that social bond that most of us who go into the health
professional field say that's why I went into this career, it is for
that social bond and that relationship that I'm interested in in providing care.
So as we think in this segment, we really focused on patient centered care, and we
gave you some tips and tools about how to use patient centered communication skills.
How you might interact that in the medical interview to demonstrate aspects
of culturally appropriate care, express through cultural humility
that anyone across all the health care professions can use in the future.
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