SlideShare a Scribd company logo
1 of 22
Download to read offline
Mark Sullivan, MD PhD
University ofWashington
Psychiatry and Behavioral Sciences
Anesthesiology and Pain Medicine
Bioethics and Humanities
 Overall question:
 How do we personalize care in a health care system
organized around an impersonal and objective
medical diagnosis?
 Personalization of care
 Patient-centered care vs activated patient
 Personalization of treatment choice
 Respecting vs. promoting autonomy
 Personalizing outcome assessment
 HRQL vs PCH as capacity for action
 Overall question:
 How are we to understand and promote the
patient’s participation in the production of health?
 Concept of health behavior retards
innovation in chronic illness care
 We seek not just an activated patient, but an
autonomous patient who sets and pursues her
own vital goals.
 To fully enlist patients, we must bridge the
gap between impersonal disease processes
and personal life processes.
 We must understand how the roots of patient
autonomy lie in the biological autonomy that
allows organisms to carve their biological niche.
 Patient agency is both the primary means
and primary end of health care.
 Extrinsic: healthy action produces health-
diet, exercise, medication adherence
 Unavoidable in chronic illness care
 Intrinsic: meaningful action is a component of
health- acting is being healthy,
 Can mitigate and retard progress of pathology
 Organ impairments, activity restrictions,
participation limitations– circular relationship
 Past: Compliance, adherence
 Provide information to obedient patient
 Present: self-management of chronic illness
 Provides skills in responsive system (CCM)
 Patient goals=clinician goals (A1c, LDL, SBP)
 Future: patient empowerment
 patient’s vital goals  clinical goals
 Focus on maintenance of healthy action
 Emphasize intrinsic rather than extrinsic motivation
 From behavior to intentional action
 Bandura: patients “are agents of experience rather
than simply undergoers of experience.”
 Shift from reinforcers to confidence allowed advance
from predicting to changing behavior
 From confidence to personal importance
motivational interviewing (MI)
 elicit rather than instill motivation for change
 move conflict between aspirations and actions
inside the patient
Theory
Social Cognitive
Theory (SCT)
MotivationaI
Interviewing (MI)
Health Action
Process Approach
(TTM or HAPA)
Self-Determination
Theory (SDT)
Shared Decision
Making (SDM)
Patient
Empowerment
Process Self-management (clinician goals, self vs. disease) Self-transformation (internalized and intrinsic motivation
Goals for behavior
change
[MEANS]
Goals are product
of capabilities
(self-efficacy,
outcome
expectancies)
[CONFIDENCE]
Goals arise from
clinician agenda,
who seeks
grounds in patient
aspirations
[IMPORTANCE]
Operationalizes
intention formation
(goal setting)
[IMPORTANCE]
separately from
action execution
(goal pursuit)
[CONFIDENCE]
Specifies ultimate
goals: autonomy,
relatedness, and
competence, but
not proximate
change goals
[INTERNALIZATION]
Unlike classical
informed consent,
both means and
ends are
negotiable
[HEALING
DIALOGUE]
Abjures pursuit of
adherence in favor
of facilitating
patient goal pursuit
[AUTONOMY]
Self who takes
action
Self is self-
reflexive and
socially shaped
Self as site of
potential
ambivalence to be
drawn upon
Health behavior
seen as part of
Health self-
regulation
Altered by
internalization of
new goals; as goals
become intrinsic,
self is transformed
Self of patient is in
dialogue with
clinician, and may
be altered in the
process (rather
than a stable self,
giving permission:
informed consent)
Empowerment
explicitly aims for
transformation of
the patient rather
than just self-
management of
illness
Focus: what is to be changed, how to change why change, who is changing
 maintenance of new health behaviors
requires patients to internalize both skills
and values for change
 Internalization promoted by support of:
 Autonomy: act intentionally c/w values
 Competence: confidence plus agency
 Relatedness: inclination to seek close relat.
 Effective for tobacco cessation, physical activity, weight loss,
diabetes management, dental health, medication adherence
 SDM vs informed consent
 Aim: promoting vs. respecting autonomy
 Refusals: negotiated not simply honored
 Role: part of care not prior to care
 Application: “preference sensitive decisions”
 Setting: chronic rather than acute care
 Process: collaboration rather than permission
 Focus: goals rather than means
 Self-mgmt. of disease separate from self
 Mgmt. dictated by nature of disease
 Manage diabetes as professional would
 Little attention to threats to identity
 Consider self-management of depression
 Focused on both disease and person
 Disease goals and personal goals relevant
 Not just adherence, but agency and autonomy
 “The empowerment approach requires changing from
feeling responsible for patients to feeling responsible to
patients.”--- Robert Anderson and Martha Funnell
 Empowerment is more about self-determination than
self-management. “It is more a question of what you are
than what you do.” (Aujoulat)
 Empowerment is a combination of competence and
autonomous self-regulation (Geoffrey Williams, SDT)
 Empowerment as clinical process or outcome?
 Process: as a means toward other health outcomes:A1c, LDL…
 Outcome: as a component of health or marker of health
 Empowerment as fostering autonomy
 Fostering the development of the patient as a subject in
psychoanalysis and in diabetes care
 Physicians are classically responsible for their patients, analysts are
responsible to their patients.
 Raises the basic ethical question: how should you live your life?
Trial types Efficacy Effectiveness Empowerment
What is tested Treatment Treatment-clinical
context
Engagement-
inspiration
Scientific strength Internal validity External validity Ecological validity
Treatment target Disease Disease in context Health
Treatment goal Cure, remission,
surrogate
Remission,
improvement
Autonomy
Biological / personal
Therapy-patient
relationship
Patient removed as
much as possible
Patient included in
selection and use of
means of care
Patient fully included
in selection of means
and goals of care
Role of adherence Adherence minimized Adherence
incorporated
Adherence surpassed
Source of therapeutic
action
Clinician-treatment Clinician and patient Patient + supports
 We aim to treat disease through the patient
(effectiveness) rather than around the patient (efficacy).
 With empowerment, we not only treat through the
patient, but on the patient’s terms and toward the
patient’s goals. Knowing the patient becomes as important
as knowing the disease.
 The clinician has a much more ambitious task than
respecting patient preferences, a common definition of
patient-centeredness. If the clinician is to not only respect
but promote patient autonomy, he needs to know how to
“promote the development of the patient as a subject.”
 We have been interested in how patient
action causes patient health.We have
examined patient action as a means to
patient health: mortality, morbidity, A1c…
 We will now examine how the capacity for
patient action is patient health.
 Healthy organisms are active organisms, not
simply surviving or defusing environmental
perturbations, but shaping their environment
to their own ends.
 Patient autonomy on a personal level is
ultimately rooted in biological autonomy on a
sub-personal level.
 All healthy organisms have the capacity, not
only to maintain themselves in the face of
environmental stresses (homestasis), but to
actively carve an environmental niche.
 Beneath the power of humans to make
autonomous choices, lies the basic power of
organisms to initiate movement or action.
 Modern biological science explains events
mechanically in terms of causes that precede
events, not goals that follow these events.
 Mechanical explanations are claimed to be
exhaustive and complete.
 But compare kicking a ball vs kicking a dog
 Both move after being kicked
 The ball moves according to the force of the kick
 The dog moves according to the meaning of the kick
 The capacity for action is common to basic organisms that
have only biological autonomy and to humans that also
have personal (decisional) autonomy. It is this capacity for
action that I am defining as the essence of patient-
centered health.
 This primacy of action means that the most fundamental
form of self-awareness is not the “I think” of Descartes,
but “I can.”
 The healthy body is perceived as “I can,” for it is
fundamentally a vehicle for action.The unhealthy body is
a barrier to action.The healthy body is a transparent
window onto the world, the unhealthy body is a wall
between us and the world.
Patient as Health Care
Chooser (Ch 3-4)
patient autonomy
informed consent to
treatments
Patient as Health
Perceiver (Ch 5-6)
patient-reported outcomes
SRH: self-rated health
Health-Related Quality of
Life (HRQL)
health-state utilities
Patient as Health
Creator (Ch 9-10)
infection resistance
vitality and vitalism
Biological autonomy
Niche construction
Patient as Health
Actor (Ch 7-8)
health behavior
treatment adherence
preventive medicine
shared decision-making
Patient choosing health care
vs.
Patient participation in health care
What is the link between vitality and longevity?
Is self-rated health a state (of biological order)
or a capacity (for ordering the environment)?
FOUR FACETS OF PATIENT ACTION
Patient supplying values
vs.
Patient supplying facts
Nature of clinical problem
Criteria for effective treatment
How does agency in non-
health behavior domains
produce health benefits?
 In order to meet the
challenge of chronic
illness, we must promote
patient participation in the
production of health.
 Patients are the primary
producers and perceivers
of health.
 Available from Oxford or
Amazon
 markdsullivan.org

More Related Content

What's hot

behavioural models in health promotion
behavioural models in health promotionbehavioural models in health promotion
behavioural models in health promotionBala Vidyadhar
 
Holistic nursing research
Holistic nursing researchHolistic nursing research
Holistic nursing researchMaybelle Animas
 
Organizational Contex and Patient Safety: Is there a Role for Mindfulness?
Organizational Contex and Patient Safety: Is there a Role for Mindfulness?Organizational Contex and Patient Safety: Is there a Role for Mindfulness?
Organizational Contex and Patient Safety: Is there a Role for Mindfulness?Heather Gilmartin
 
Modification of health behaviors
Modification of health behaviorsModification of health behaviors
Modification of health behaviorsNaila Pachani
 
Jhu fall 2011 group 5 hbm t heory ppt due 11 21-2011
Jhu fall 2011 group 5 hbm t heory ppt due 11 21-2011Jhu fall 2011 group 5 hbm t heory ppt due 11 21-2011
Jhu fall 2011 group 5 hbm t heory ppt due 11 21-2011tatia30
 
Group 7 ethics group wiki_hpm_smoking
Group 7 ethics group wiki_hpm_smokingGroup 7 ethics group wiki_hpm_smoking
Group 7 ethics group wiki_hpm_smokingThao Nguyen
 
Conceptual framework on health Belief model
Conceptual framework on health Belief modelConceptual framework on health Belief model
Conceptual framework on health Belief modelDeblina Roy
 
Integrative medicine and_patient_centered_care
Integrative medicine and_patient_centered_careIntegrative medicine and_patient_centered_care
Integrative medicine and_patient_centered_careenergiaprimordialreiki
 
Fundamentals of nursing
Fundamentals of nursingFundamentals of nursing
Fundamentals of nursinggrey clemente
 
Chapter 11 health behavior theories
Chapter 11 health behavior theoriesChapter 11 health behavior theories
Chapter 11 health behavior theoriesstanbridge
 
Ida Jean Orlando’s Nursing Process Theory
Ida Jean Orlando’s Nursing Process TheoryIda Jean Orlando’s Nursing Process Theory
Ida Jean Orlando’s Nursing Process TheoryJosephine Ann Necor
 
Abdellah’s theory
Abdellah’s theoryAbdellah’s theory
Abdellah’s theoryNEHA BHARTI
 
Transition from allopathic to integrated practice
Transition from allopathic to integrated practiceTransition from allopathic to integrated practice
Transition from allopathic to integrated practiceLouis Cady, MD
 
Holistic nurse coaching
Holistic nurse coaching Holistic nurse coaching
Holistic nurse coaching BenHarper34
 
Crimson Publishers-Narrative and Meaning of Life: How Mental Health Nurses ca...
Crimson Publishers-Narrative and Meaning of Life: How Mental Health Nurses ca...Crimson Publishers-Narrative and Meaning of Life: How Mental Health Nurses ca...
Crimson Publishers-Narrative and Meaning of Life: How Mental Health Nurses ca...CrimsonpublishersPPrs
 

What's hot (19)

behavioural models in health promotion
behavioural models in health promotionbehavioural models in health promotion
behavioural models in health promotion
 
Holistic nursing research
Holistic nursing researchHolistic nursing research
Holistic nursing research
 
Organizational Contex and Patient Safety: Is there a Role for Mindfulness?
Organizational Contex and Patient Safety: Is there a Role for Mindfulness?Organizational Contex and Patient Safety: Is there a Role for Mindfulness?
Organizational Contex and Patient Safety: Is there a Role for Mindfulness?
 
Modification of health behaviors
Modification of health behaviorsModification of health behaviors
Modification of health behaviors
 
Jhu fall 2011 group 5 hbm t heory ppt due 11 21-2011
Jhu fall 2011 group 5 hbm t heory ppt due 11 21-2011Jhu fall 2011 group 5 hbm t heory ppt due 11 21-2011
Jhu fall 2011 group 5 hbm t heory ppt due 11 21-2011
 
Group 7 ethics group wiki_hpm_smoking
Group 7 ethics group wiki_hpm_smokingGroup 7 ethics group wiki_hpm_smoking
Group 7 ethics group wiki_hpm_smoking
 
Holistic model
Holistic modelHolistic model
Holistic model
 
Resilience trauma-pastoral-recovery
Resilience trauma-pastoral-recoveryResilience trauma-pastoral-recovery
Resilience trauma-pastoral-recovery
 
Conceptual framework on health Belief model
Conceptual framework on health Belief modelConceptual framework on health Belief model
Conceptual framework on health Belief model
 
Integrative medicine and_patient_centered_care
Integrative medicine and_patient_centered_careIntegrative medicine and_patient_centered_care
Integrative medicine and_patient_centered_care
 
Fundamentals of nursing
Fundamentals of nursingFundamentals of nursing
Fundamentals of nursing
 
Health belief model
Health belief modelHealth belief model
Health belief model
 
Chapter 11 health behavior theories
Chapter 11 health behavior theoriesChapter 11 health behavior theories
Chapter 11 health behavior theories
 
Ida Jean Orlando’s Nursing Process Theory
Ida Jean Orlando’s Nursing Process TheoryIda Jean Orlando’s Nursing Process Theory
Ida Jean Orlando’s Nursing Process Theory
 
Abdellah’s theory
Abdellah’s theoryAbdellah’s theory
Abdellah’s theory
 
Transition from allopathic to integrated practice
Transition from allopathic to integrated practiceTransition from allopathic to integrated practice
Transition from allopathic to integrated practice
 
Holistic nurse coaching
Holistic nurse coaching Holistic nurse coaching
Holistic nurse coaching
 
Crimson Publishers-Narrative and Meaning of Life: How Mental Health Nurses ca...
Crimson Publishers-Narrative and Meaning of Life: How Mental Health Nurses ca...Crimson Publishers-Narrative and Meaning of Life: How Mental Health Nurses ca...
Crimson Publishers-Narrative and Meaning of Life: How Mental Health Nurses ca...
 
Holistic nursing
Holistic nursingHolistic nursing
Holistic nursing
 

Similar to Promoting Patient Participation in Health Production

The Patient As Agent: precis
The Patient As Agent: precisThe Patient As Agent: precis
The Patient As Agent: precisMark Sullivan
 
Patient Agency: a focus for integrated care
Patient Agency: a focus for integrated carePatient Agency: a focus for integrated care
Patient Agency: a focus for integrated careMark Sullivan
 
Sociology 3 health behaviour
Sociology 3 health behaviourSociology 3 health behaviour
Sociology 3 health behaviourmonaaboserea
 
sociology3healthbehaviour-190406154029.pdf
sociology3healthbehaviour-190406154029.pdfsociology3healthbehaviour-190406154029.pdf
sociology3healthbehaviour-190406154029.pdfaidamohamed12
 
Pender's health promotion
Pender's health promotionPender's health promotion
Pender's health promotionFaye Nang
 
Psychological Factors influence on health
Psychological Factors influence on healthPsychological Factors influence on health
Psychological Factors influence on healthAQSA SHAHID
 
1introduction of msn & concept of health
1introduction of msn & concept of health1introduction of msn & concept of health
1introduction of msn & concept of healthMR. JAGDISH SAMBAD
 
1introductionofmsnconceptofhealth-181004172918 (1).pdf
1introductionofmsnconceptofhealth-181004172918 (1).pdf1introductionofmsnconceptofhealth-181004172918 (1).pdf
1introductionofmsnconceptofhealth-181004172918 (1).pdfMohammedKasim29
 
Holism, empowerment and subjectivity, Helen Madden
Holism, empowerment and subjectivity, Helen MaddenHolism, empowerment and subjectivity, Helen Madden
Holism, empowerment and subjectivity, Helen MaddenNZ Psychological Society
 
Module 5-Ethics in Different Domain.pptx
Module 5-Ethics in Different Domain.pptxModule 5-Ethics in Different Domain.pptx
Module 5-Ethics in Different Domain.pptxAmandeepKaur120355
 
Concept of health and illness
Concept of health and illnessConcept of health and illness
Concept of health and illnessYoussef2000
 
INTRODUCTORY CONCEPTS of fundamentals of nursing
INTRODUCTORY CONCEPTS of fundamentals of nursingINTRODUCTORY CONCEPTS of fundamentals of nursing
INTRODUCTORY CONCEPTS of fundamentals of nursingJRRolfNeuqelet
 
Doctor-Patient_Relationship.ppt
Doctor-Patient_Relationship.pptDoctor-Patient_Relationship.ppt
Doctor-Patient_Relationship.pptssuseref3feb
 
Health and illness 7.28.pptx
Health and illness 7.28.pptxHealth and illness 7.28.pptx
Health and illness 7.28.pptxNarayanNeupane3
 
Illness cognition and cognitive behavioral approches
Illness cognition and cognitive behavioral approchesIllness cognition and cognitive behavioral approches
Illness cognition and cognitive behavioral approchesMishaRiaz
 
UNIT 1 INTRODUCTION FUNDAMENTALS OF NURSING
UNIT 1 INTRODUCTION FUNDAMENTALS OF NURSINGUNIT 1 INTRODUCTION FUNDAMENTALS OF NURSING
UNIT 1 INTRODUCTION FUNDAMENTALS OF NURSINGVemuJhansi
 

Similar to Promoting Patient Participation in Health Production (20)

The Patient As Agent: precis
The Patient As Agent: precisThe Patient As Agent: precis
The Patient As Agent: precis
 
Patient Agency: a focus for integrated care
Patient Agency: a focus for integrated carePatient Agency: a focus for integrated care
Patient Agency: a focus for integrated care
 
Sociology 3 health behaviour
Sociology 3 health behaviourSociology 3 health behaviour
Sociology 3 health behaviour
 
sociology3healthbehaviour-190406154029.pdf
sociology3healthbehaviour-190406154029.pdfsociology3healthbehaviour-190406154029.pdf
sociology3healthbehaviour-190406154029.pdf
 
Pender's health promotion
Pender's health promotionPender's health promotion
Pender's health promotion
 
unit 1 MSN-1.pptx
unit 1 MSN-1.pptxunit 1 MSN-1.pptx
unit 1 MSN-1.pptx
 
Psychological Factors influence on health
Psychological Factors influence on healthPsychological Factors influence on health
Psychological Factors influence on health
 
1introduction of msn & concept of health
1introduction of msn & concept of health1introduction of msn & concept of health
1introduction of msn & concept of health
 
1introductionofmsnconceptofhealth-181004172918 (1).pdf
1introductionofmsnconceptofhealth-181004172918 (1).pdf1introductionofmsnconceptofhealth-181004172918 (1).pdf
1introductionofmsnconceptofhealth-181004172918 (1).pdf
 
Holism, empowerment and subjectivity, Helen Madden
Holism, empowerment and subjectivity, Helen MaddenHolism, empowerment and subjectivity, Helen Madden
Holism, empowerment and subjectivity, Helen Madden
 
Module 5-Ethics in Different Domain.pptx
Module 5-Ethics in Different Domain.pptxModule 5-Ethics in Different Domain.pptx
Module 5-Ethics in Different Domain.pptx
 
Health & Illness .pptx
Health & Illness .pptxHealth & Illness .pptx
Health & Illness .pptx
 
Concept of health and illness
Concept of health and illnessConcept of health and illness
Concept of health and illness
 
INTRODUCTORY CONCEPTS of fundamentals of nursing
INTRODUCTORY CONCEPTS of fundamentals of nursingINTRODUCTORY CONCEPTS of fundamentals of nursing
INTRODUCTORY CONCEPTS of fundamentals of nursing
 
Autonomy in Bioethics
Autonomy in BioethicsAutonomy in Bioethics
Autonomy in Bioethics
 
Doctor-Patient_Relationship.ppt
Doctor-Patient_Relationship.pptDoctor-Patient_Relationship.ppt
Doctor-Patient_Relationship.ppt
 
Health and illness 7.28.pptx
Health and illness 7.28.pptxHealth and illness 7.28.pptx
Health and illness 7.28.pptx
 
Illness cognition and cognitive behavioral approches
Illness cognition and cognitive behavioral approchesIllness cognition and cognitive behavioral approches
Illness cognition and cognitive behavioral approches
 
UNIT 1 INTRODUCTION FUNDAMENTALS OF NURSING
UNIT 1 INTRODUCTION FUNDAMENTALS OF NURSINGUNIT 1 INTRODUCTION FUNDAMENTALS OF NURSING
UNIT 1 INTRODUCTION FUNDAMENTALS OF NURSING
 
Comfort Care Advantages
Comfort Care AdvantagesComfort Care Advantages
Comfort Care Advantages
 

Recently uploaded

Presentation on Non Steroidal Anti-inflammatory Agents
Presentation on Non Steroidal Anti-inflammatory AgentsPresentation on Non Steroidal Anti-inflammatory Agents
Presentation on Non Steroidal Anti-inflammatory AgentsPrerana Jadhav
 
SHOCK (Medical SURGICAL BASED EDITION)).pptx
SHOCK (Medical SURGICAL BASED EDITION)).pptxSHOCK (Medical SURGICAL BASED EDITION)).pptx
SHOCK (Medical SURGICAL BASED EDITION)).pptxAbhishek943418
 
NEWER OHAs AND NEWER INSULIN.pptx
NEWER OHAs        AND NEWER INSULIN.pptxNEWER OHAs        AND NEWER INSULIN.pptx
NEWER OHAs AND NEWER INSULIN.pptxtarakeeshbai1802
 
Plant Fibres used as Surgical Dressings PDF.pdf
Plant Fibres used as Surgical Dressings PDF.pdfPlant Fibres used as Surgical Dressings PDF.pdf
Plant Fibres used as Surgical Dressings PDF.pdfDivya Kanojiya
 
Study on the Impact of FOCUS-PDCA Management Model on the Disinfection Qualit...
Study on the Impact of FOCUS-PDCA Management Model on the Disinfection Qualit...Study on the Impact of FOCUS-PDCA Management Model on the Disinfection Qualit...
Study on the Impact of FOCUS-PDCA Management Model on the Disinfection Qualit...MehranMouzam
 
ANEMIA IN PREGNANCY by Dr. Akebom Kidanemariam
ANEMIA IN PREGNANCY by Dr. Akebom KidanemariamANEMIA IN PREGNANCY by Dr. Akebom Kidanemariam
ANEMIA IN PREGNANCY by Dr. Akebom KidanemariamAkebom Gebremichael
 
Musculoskeletal disorders: Osteoarthritis,.pptx
Musculoskeletal disorders: Osteoarthritis,.pptxMusculoskeletal disorders: Osteoarthritis,.pptx
Musculoskeletal disorders: Osteoarthritis,.pptxraviapr7
 
Presentació "Real-Life VR Integration for Mild Cognitive Impairment Rehabilit...
Presentació "Real-Life VR Integration for Mild Cognitive Impairment Rehabilit...Presentació "Real-Life VR Integration for Mild Cognitive Impairment Rehabilit...
Presentació "Real-Life VR Integration for Mild Cognitive Impairment Rehabilit...Badalona Serveis Assistencials
 
CPCSEA guidelines and IAEC committee.pptx
CPCSEA guidelines and IAEC committee.pptxCPCSEA guidelines and IAEC committee.pptx
CPCSEA guidelines and IAEC committee.pptxMs. Kiran Divekar
 
Units of Radiation Measurements, Quality Specification, Half-Value Thickness,...
Units of Radiation Measurements, Quality Specification, Half-Value Thickness,...Units of Radiation Measurements, Quality Specification, Half-Value Thickness,...
Units of Radiation Measurements, Quality Specification, Half-Value Thickness,...Dr. Dheeraj Kumar
 
Presentation for Bella Mahl 2024-03-28-24-MW-Overview-Bella.pptx
Presentation for Bella Mahl 2024-03-28-24-MW-Overview-Bella.pptxPresentation for Bella Mahl 2024-03-28-24-MW-Overview-Bella.pptx
Presentation for Bella Mahl 2024-03-28-24-MW-Overview-Bella.pptxpdamico1
 
PHYSIOTHERAPY IN HEART TRANSPLANTATION..
PHYSIOTHERAPY IN HEART TRANSPLANTATION..PHYSIOTHERAPY IN HEART TRANSPLANTATION..
PHYSIOTHERAPY IN HEART TRANSPLANTATION..AneriPatwari
 
Nutrition of OCD for my Nutritional Neuroscience Class
Nutrition of OCD for my Nutritional Neuroscience ClassNutrition of OCD for my Nutritional Neuroscience Class
Nutrition of OCD for my Nutritional Neuroscience Classmanuelazg2001
 
Rapid Release Granulation Technology ppt
Rapid Release Granulation Technology pptRapid Release Granulation Technology ppt
Rapid Release Granulation Technology pptHasnat Tariq
 
Culture and Health Disorders Social change.pptx
Culture and Health Disorders Social change.pptxCulture and Health Disorders Social change.pptx
Culture and Health Disorders Social change.pptxDr. Dheeraj Kumar
 
Phytochemical Investigation of Drugs PDF.pdf
Phytochemical Investigation of Drugs PDF.pdfPhytochemical Investigation of Drugs PDF.pdf
Phytochemical Investigation of Drugs PDF.pdfDivya Kanojiya
 
Prince Paulraj W HERBAL DRUG TECHNO.pptx
Prince Paulraj W HERBAL DRUG TECHNO.pptxPrince Paulraj W HERBAL DRUG TECHNO.pptx
Prince Paulraj W HERBAL DRUG TECHNO.pptxprincebieber28
 
Ophthalmology Ultrasound Training Course
Ophthalmology Ultrasound Training CourseOphthalmology Ultrasound Training Course
Ophthalmology Ultrasound Training CourseKafrELShiekh University
 
Screening for colorectal cancer AAU.pptx
Screening for colorectal cancer AAU.pptxScreening for colorectal cancer AAU.pptx
Screening for colorectal cancer AAU.pptxtadehabte
 
Aditi Jagtap (Daughter of Ranjit Jagtap).pdf
Aditi Jagtap (Daughter of Ranjit Jagtap).pdfAditi Jagtap (Daughter of Ranjit Jagtap).pdf
Aditi Jagtap (Daughter of Ranjit Jagtap).pdfAditi Jagtap Pune
 

Recently uploaded (20)

Presentation on Non Steroidal Anti-inflammatory Agents
Presentation on Non Steroidal Anti-inflammatory AgentsPresentation on Non Steroidal Anti-inflammatory Agents
Presentation on Non Steroidal Anti-inflammatory Agents
 
SHOCK (Medical SURGICAL BASED EDITION)).pptx
SHOCK (Medical SURGICAL BASED EDITION)).pptxSHOCK (Medical SURGICAL BASED EDITION)).pptx
SHOCK (Medical SURGICAL BASED EDITION)).pptx
 
NEWER OHAs AND NEWER INSULIN.pptx
NEWER OHAs        AND NEWER INSULIN.pptxNEWER OHAs        AND NEWER INSULIN.pptx
NEWER OHAs AND NEWER INSULIN.pptx
 
Plant Fibres used as Surgical Dressings PDF.pdf
Plant Fibres used as Surgical Dressings PDF.pdfPlant Fibres used as Surgical Dressings PDF.pdf
Plant Fibres used as Surgical Dressings PDF.pdf
 
Study on the Impact of FOCUS-PDCA Management Model on the Disinfection Qualit...
Study on the Impact of FOCUS-PDCA Management Model on the Disinfection Qualit...Study on the Impact of FOCUS-PDCA Management Model on the Disinfection Qualit...
Study on the Impact of FOCUS-PDCA Management Model on the Disinfection Qualit...
 
ANEMIA IN PREGNANCY by Dr. Akebom Kidanemariam
ANEMIA IN PREGNANCY by Dr. Akebom KidanemariamANEMIA IN PREGNANCY by Dr. Akebom Kidanemariam
ANEMIA IN PREGNANCY by Dr. Akebom Kidanemariam
 
Musculoskeletal disorders: Osteoarthritis,.pptx
Musculoskeletal disorders: Osteoarthritis,.pptxMusculoskeletal disorders: Osteoarthritis,.pptx
Musculoskeletal disorders: Osteoarthritis,.pptx
 
Presentació "Real-Life VR Integration for Mild Cognitive Impairment Rehabilit...
Presentació "Real-Life VR Integration for Mild Cognitive Impairment Rehabilit...Presentació "Real-Life VR Integration for Mild Cognitive Impairment Rehabilit...
Presentació "Real-Life VR Integration for Mild Cognitive Impairment Rehabilit...
 
CPCSEA guidelines and IAEC committee.pptx
CPCSEA guidelines and IAEC committee.pptxCPCSEA guidelines and IAEC committee.pptx
CPCSEA guidelines and IAEC committee.pptx
 
Units of Radiation Measurements, Quality Specification, Half-Value Thickness,...
Units of Radiation Measurements, Quality Specification, Half-Value Thickness,...Units of Radiation Measurements, Quality Specification, Half-Value Thickness,...
Units of Radiation Measurements, Quality Specification, Half-Value Thickness,...
 
Presentation for Bella Mahl 2024-03-28-24-MW-Overview-Bella.pptx
Presentation for Bella Mahl 2024-03-28-24-MW-Overview-Bella.pptxPresentation for Bella Mahl 2024-03-28-24-MW-Overview-Bella.pptx
Presentation for Bella Mahl 2024-03-28-24-MW-Overview-Bella.pptx
 
PHYSIOTHERAPY IN HEART TRANSPLANTATION..
PHYSIOTHERAPY IN HEART TRANSPLANTATION..PHYSIOTHERAPY IN HEART TRANSPLANTATION..
PHYSIOTHERAPY IN HEART TRANSPLANTATION..
 
Nutrition of OCD for my Nutritional Neuroscience Class
Nutrition of OCD for my Nutritional Neuroscience ClassNutrition of OCD for my Nutritional Neuroscience Class
Nutrition of OCD for my Nutritional Neuroscience Class
 
Rapid Release Granulation Technology ppt
Rapid Release Granulation Technology pptRapid Release Granulation Technology ppt
Rapid Release Granulation Technology ppt
 
Culture and Health Disorders Social change.pptx
Culture and Health Disorders Social change.pptxCulture and Health Disorders Social change.pptx
Culture and Health Disorders Social change.pptx
 
Phytochemical Investigation of Drugs PDF.pdf
Phytochemical Investigation of Drugs PDF.pdfPhytochemical Investigation of Drugs PDF.pdf
Phytochemical Investigation of Drugs PDF.pdf
 
Prince Paulraj W HERBAL DRUG TECHNO.pptx
Prince Paulraj W HERBAL DRUG TECHNO.pptxPrince Paulraj W HERBAL DRUG TECHNO.pptx
Prince Paulraj W HERBAL DRUG TECHNO.pptx
 
Ophthalmology Ultrasound Training Course
Ophthalmology Ultrasound Training CourseOphthalmology Ultrasound Training Course
Ophthalmology Ultrasound Training Course
 
Screening for colorectal cancer AAU.pptx
Screening for colorectal cancer AAU.pptxScreening for colorectal cancer AAU.pptx
Screening for colorectal cancer AAU.pptx
 
Aditi Jagtap (Daughter of Ranjit Jagtap).pdf
Aditi Jagtap (Daughter of Ranjit Jagtap).pdfAditi Jagtap (Daughter of Ranjit Jagtap).pdf
Aditi Jagtap (Daughter of Ranjit Jagtap).pdf
 

Promoting Patient Participation in Health Production

  • 1. Mark Sullivan, MD PhD University ofWashington Psychiatry and Behavioral Sciences Anesthesiology and Pain Medicine Bioethics and Humanities
  • 2.  Overall question:  How do we personalize care in a health care system organized around an impersonal and objective medical diagnosis?  Personalization of care  Patient-centered care vs activated patient  Personalization of treatment choice  Respecting vs. promoting autonomy  Personalizing outcome assessment  HRQL vs PCH as capacity for action
  • 3.  Overall question:  How are we to understand and promote the patient’s participation in the production of health?  Concept of health behavior retards innovation in chronic illness care  We seek not just an activated patient, but an autonomous patient who sets and pursues her own vital goals.
  • 4.  To fully enlist patients, we must bridge the gap between impersonal disease processes and personal life processes.  We must understand how the roots of patient autonomy lie in the biological autonomy that allows organisms to carve their biological niche.  Patient agency is both the primary means and primary end of health care.
  • 5.
  • 6.  Extrinsic: healthy action produces health- diet, exercise, medication adherence  Unavoidable in chronic illness care  Intrinsic: meaningful action is a component of health- acting is being healthy,  Can mitigate and retard progress of pathology  Organ impairments, activity restrictions, participation limitations– circular relationship
  • 7.  Past: Compliance, adherence  Provide information to obedient patient  Present: self-management of chronic illness  Provides skills in responsive system (CCM)  Patient goals=clinician goals (A1c, LDL, SBP)  Future: patient empowerment  patient’s vital goals  clinical goals  Focus on maintenance of healthy action  Emphasize intrinsic rather than extrinsic motivation
  • 8.  From behavior to intentional action  Bandura: patients “are agents of experience rather than simply undergoers of experience.”  Shift from reinforcers to confidence allowed advance from predicting to changing behavior  From confidence to personal importance motivational interviewing (MI)  elicit rather than instill motivation for change  move conflict between aspirations and actions inside the patient
  • 9. Theory Social Cognitive Theory (SCT) MotivationaI Interviewing (MI) Health Action Process Approach (TTM or HAPA) Self-Determination Theory (SDT) Shared Decision Making (SDM) Patient Empowerment Process Self-management (clinician goals, self vs. disease) Self-transformation (internalized and intrinsic motivation Goals for behavior change [MEANS] Goals are product of capabilities (self-efficacy, outcome expectancies) [CONFIDENCE] Goals arise from clinician agenda, who seeks grounds in patient aspirations [IMPORTANCE] Operationalizes intention formation (goal setting) [IMPORTANCE] separately from action execution (goal pursuit) [CONFIDENCE] Specifies ultimate goals: autonomy, relatedness, and competence, but not proximate change goals [INTERNALIZATION] Unlike classical informed consent, both means and ends are negotiable [HEALING DIALOGUE] Abjures pursuit of adherence in favor of facilitating patient goal pursuit [AUTONOMY] Self who takes action Self is self- reflexive and socially shaped Self as site of potential ambivalence to be drawn upon Health behavior seen as part of Health self- regulation Altered by internalization of new goals; as goals become intrinsic, self is transformed Self of patient is in dialogue with clinician, and may be altered in the process (rather than a stable self, giving permission: informed consent) Empowerment explicitly aims for transformation of the patient rather than just self- management of illness Focus: what is to be changed, how to change why change, who is changing
  • 10.  maintenance of new health behaviors requires patients to internalize both skills and values for change  Internalization promoted by support of:  Autonomy: act intentionally c/w values  Competence: confidence plus agency  Relatedness: inclination to seek close relat.  Effective for tobacco cessation, physical activity, weight loss, diabetes management, dental health, medication adherence
  • 11.  SDM vs informed consent  Aim: promoting vs. respecting autonomy  Refusals: negotiated not simply honored  Role: part of care not prior to care  Application: “preference sensitive decisions”  Setting: chronic rather than acute care  Process: collaboration rather than permission  Focus: goals rather than means
  • 12.  Self-mgmt. of disease separate from self  Mgmt. dictated by nature of disease  Manage diabetes as professional would  Little attention to threats to identity  Consider self-management of depression  Focused on both disease and person  Disease goals and personal goals relevant  Not just adherence, but agency and autonomy
  • 13.  “The empowerment approach requires changing from feeling responsible for patients to feeling responsible to patients.”--- Robert Anderson and Martha Funnell  Empowerment is more about self-determination than self-management. “It is more a question of what you are than what you do.” (Aujoulat)  Empowerment is a combination of competence and autonomous self-regulation (Geoffrey Williams, SDT)
  • 14.  Empowerment as clinical process or outcome?  Process: as a means toward other health outcomes:A1c, LDL…  Outcome: as a component of health or marker of health  Empowerment as fostering autonomy  Fostering the development of the patient as a subject in psychoanalysis and in diabetes care  Physicians are classically responsible for their patients, analysts are responsible to their patients.  Raises the basic ethical question: how should you live your life?
  • 15. Trial types Efficacy Effectiveness Empowerment What is tested Treatment Treatment-clinical context Engagement- inspiration Scientific strength Internal validity External validity Ecological validity Treatment target Disease Disease in context Health Treatment goal Cure, remission, surrogate Remission, improvement Autonomy Biological / personal Therapy-patient relationship Patient removed as much as possible Patient included in selection and use of means of care Patient fully included in selection of means and goals of care Role of adherence Adherence minimized Adherence incorporated Adherence surpassed Source of therapeutic action Clinician-treatment Clinician and patient Patient + supports
  • 16.  We aim to treat disease through the patient (effectiveness) rather than around the patient (efficacy).  With empowerment, we not only treat through the patient, but on the patient’s terms and toward the patient’s goals. Knowing the patient becomes as important as knowing the disease.  The clinician has a much more ambitious task than respecting patient preferences, a common definition of patient-centeredness. If the clinician is to not only respect but promote patient autonomy, he needs to know how to “promote the development of the patient as a subject.”
  • 17.  We have been interested in how patient action causes patient health.We have examined patient action as a means to patient health: mortality, morbidity, A1c…  We will now examine how the capacity for patient action is patient health.  Healthy organisms are active organisms, not simply surviving or defusing environmental perturbations, but shaping their environment to their own ends.
  • 18.  Patient autonomy on a personal level is ultimately rooted in biological autonomy on a sub-personal level.  All healthy organisms have the capacity, not only to maintain themselves in the face of environmental stresses (homestasis), but to actively carve an environmental niche.  Beneath the power of humans to make autonomous choices, lies the basic power of organisms to initiate movement or action.
  • 19.  Modern biological science explains events mechanically in terms of causes that precede events, not goals that follow these events.  Mechanical explanations are claimed to be exhaustive and complete.  But compare kicking a ball vs kicking a dog  Both move after being kicked  The ball moves according to the force of the kick  The dog moves according to the meaning of the kick
  • 20.  The capacity for action is common to basic organisms that have only biological autonomy and to humans that also have personal (decisional) autonomy. It is this capacity for action that I am defining as the essence of patient- centered health.  This primacy of action means that the most fundamental form of self-awareness is not the “I think” of Descartes, but “I can.”  The healthy body is perceived as “I can,” for it is fundamentally a vehicle for action.The unhealthy body is a barrier to action.The healthy body is a transparent window onto the world, the unhealthy body is a wall between us and the world.
  • 21. Patient as Health Care Chooser (Ch 3-4) patient autonomy informed consent to treatments Patient as Health Perceiver (Ch 5-6) patient-reported outcomes SRH: self-rated health Health-Related Quality of Life (HRQL) health-state utilities Patient as Health Creator (Ch 9-10) infection resistance vitality and vitalism Biological autonomy Niche construction Patient as Health Actor (Ch 7-8) health behavior treatment adherence preventive medicine shared decision-making Patient choosing health care vs. Patient participation in health care What is the link between vitality and longevity? Is self-rated health a state (of biological order) or a capacity (for ordering the environment)? FOUR FACETS OF PATIENT ACTION Patient supplying values vs. Patient supplying facts Nature of clinical problem Criteria for effective treatment How does agency in non- health behavior domains produce health benefits?
  • 22.  In order to meet the challenge of chronic illness, we must promote patient participation in the production of health.  Patients are the primary producers and perceivers of health.  Available from Oxford or Amazon  markdsullivan.org