Conceptos relacionados al síndrome de burnout

As clinicians we assume that our treatment of ill patients will improve their feeling of w ell-being, with increasing economic constraints we are forced to justify certciin expensive treatments. Illness or lack of health status is a difficult concept to define, a person may be ill, but not disabled or disabled, but not ill. A persons perception of their state of health will be affected by their social class, family and friends and physiological factors. The concept of Quality of hfe wcis first used by John F. Kennedy's presidential commission (Williams.

1991), which set goals for the USA for the year 2000. But as early as the 1940's proposals were made for changing the evaluation of health care. In 1947 the World Health Organisation defined health as " a state of complete physical, mental and social well-being and not merely the absence of disease" (World Health Organisation Constitution. 1947) and Elkington later said that quality of life should be the goal aimed for by every physician for the patient (Elkington. 1966).

If we decide to measure quality of life, we must decide what parameters to measure. What constitutes an improvement in quality of life? There is general agreement that studies on health related quality of life studies should a ssess functioning in a number of important domains, : physical functioning including somatic

sensations such as physical symptoms and pain; psychological functioning including concentration and mood; social (including sexual) functioning: occupational statu s; and possibly economic statu s.

Methods of measurement.

One of the early quality of life stu d ies was devised in 1949 by Kamofsky and Burchenal as part of the evaluation of new chemotherapeutic agents, they looked at survival and objective response, but also more qualitative parameters such as performance statu s, improved mood, reduction in symptom level and a sense of well-being. A number of established methods ex ist for measuring health statu s.

Mortality rates have the advantage that they are widely available, but lack accuracy as most death certificates are written without knowledge of post-mortem fin d in gs. They take no account of chronic illness or debility and as longevity increases in an affluent society death is often due to multicausal disease and disability. Therefore survival is a measure of quantity rather than quality.

Morbidity measures take account of a wide range of diseases, but accurate statistics are difficult to collect. Therefore, morbidity statistics have been developed in a number of ways:

1. Refined indices look at specific aspects of morbidity, for example incidence and prevalence rates for specific conditions, absence from work and duration of disability. Only people who present to health professionals enter th ese statistics and thus bias is introduced and disease or "lack of health" is underestimated.

2. Disability indices measure the extent that people are able to perform the essential task s of daily liv in g . The A ctivities of Daily Living scale (Katz et al. 1963) is used in the evaluation of treatment with relation to specific groups and focuses on disability in relation to those groups. It a ssesses independence, bathing toileting etc using an ordinal scale and has been found to be predictive of outcome in patients with stroke and hip fractures (Katz et al. 1964, Katz et al. 1966) Disability measurements have the advantage that they are graded degrees of disability, but rely on comparisons with normal populations. Such normal values vary with age, sex social roles and expectations.

3. Symptom and functional indices focus on clinical symptoms and are subjective measures of d istress or disability as perceived by the affected person. An example of this is the Health Perceptions Questionnaire (Ware. 1976). This con sists of statements about personal health, the response consists of five standardized categories on a true or false answer. It lacks validity on r e -te stin g .

Well validated scores ex ist and in choosing a health profile it is preferable to modify an existing questionnaire rather than devise a new one. We have used the Nottingham Health Profile (NHP) as it has been well validated and used in patients with vascular disease. The NHP questionnaire was constructed by a group of workers at the University of Nottingham working between September 1975 and December 1981. Initially statements were collected from members of the general public describing the typical effects of ill-health, looking at the social e ffe cts, the psychological effects, the

behavioural effects and the physical effects (Hunt, McEwen and McKenna. 1986).

The questionnaire is self-adm inistered, but can be read out and filled in by an assessor.

Applications of quality of hfe assessm ents in su rgery.

The aim of quality of life studies is to allow the making of impartial judgments leading to appropriate changes in treatment practice rather than support prejudices. It may be used to a ssess the outcome of treatment, not just in terms of morbidity or mortality, but to show the improvements in quality of life brought about by new technical advances, particularly when the disease is not a major cause of mortality, but imposes severe restrictions in lifestyle. Health profiles allow the comparison of differing treatment options, allowing the monitoring of health care, which is becoming increasingly important as part of clinical audit. The selection of patients for surgery may be improved by the use of quality of life stu dies, as some patients fare badly with a certain treatment, especially if high levels of motivation are required.

CHAPTER 2.