ÙNICO.- APLICABILIDAD
PARA PROTEGER EL INTERÉS SUPERIOR DEL MENOR DEBE NOMBRARSE UN PROCURADOR ESPECIAL QUE LO REPRESENTE DE
Historically there has been a paternalistic approach to patient care which arguably has impeded the building of relationships between health care providers and service users (Coulter 1999). Increasingly however, partnership models of health care have been advocated and enshrined in current international healthcare policy (Duncan et al 2010).
Indeed in many treatment plans in primary care, outside of the addictions’ field the involvement of patients and patient groups is the norm (Rhodes et al 2002, Greenhalgh 2009). Partnership models of care have been advocated in several chronic disease management guidelines such as diabetes (DoH 2005) and many other long term conditions yet patients’ views have seldom been sought regarding how chronic illness is managed (Cooper et al 2003). The expert patient initiative was launched in 2002 in the UK which embodied the idea of a much more active patient, and of a patient centred health care system, thus reducing the power of professionals and superseding the original paternalistic approach.
Even before this, understanding that the patient is ‘‘expert’’ was identified as crucial to the role of effective care in general practice (Balint 1964). Current evidence suggests however that shared decision making has not yet been widely adopted by health professionals and significant barriers exist. Gravel et al (2006) carried out a systematic review of healthcare professionals’ perceptions of shared decision making. Perceived negatives identified were time constraints, lack of applicability due to patient characteristics and lack of applicability due to the clinical situation. Positives identified were provider motivation, beneficial impact on the clinical process, and effective impact on patient outcomes. They concluded that interventions to foster implementation of shared decisionmaking in clinical practice need to address a broad range of factors. They also identified that the majority of published studies originated from the UK and the USA which suggests a proactive approach to research in the area of shared decision making.
The RoI has lagged significantly in this area and the ICGP has only recently published the Partnership with Patients Report (ní Riain & Dempsey 2009:1).This states that ‘the focus of the ICGP is consistent
with the patientcentred approach of the Irish National Health strategy Quality and Fairness–A Health System for you (2001) and Primary Care–A New Direction (2001) and reflects the need to involve the knowledgeable patient in building a safer health system described in The National Strategy for Service User Involvement in the Irish Health Service (2008 – 2013) and the Report of the Commission on Patient Safety and Quality Assurance (2008). Drug treatment strategies are absent in these reports.
The complexity of patient participation is that both practitioner and service user might offer differing perspectives on what this participation constitutes and what role partnership plays in decision making and specifically how that translates to the management of drug misuse. The individual is the central focus of the GP consultation and the significance of partnership and relationship development between this individual and his or her GP has been an overlooked dimension in addiction research. There is evidence to demonstrate that primary care can effectively contribute to individual health (Peckham & Exworthy 2003) and the ICGP advocate that the GPs’ unique knowledge of the patient and their extended family can make a considerable contribution to the long term management of those receiving methadone (ICGP 2008).
A more useful concept of partnership from the perspective of the service user may be to understand the process by which service users and physicians attitudes and behaviour facilitate decision making, negotiation and sharing control. Sharing control and shared decision making is a partnership approach between service provider and service user which acknowledges ‘’relationship’’ as key to the process. This concept of personal relationship between practitioner and patient alike has been viewed as having a pivotal role in general practice (Stokes et
al 2004). This relationship has been described as unique, established ‘on the basis of mutual satisfaction and mutual frustration’ (Balint 1964: 249). The power issues inherent in the roles of prescriber and recipient of methadone complicate this relationship and can militate against an equal system of partnership. Criticisms of this type of relationship exist as Bourgois et al (1997:155) state that social suffering is inevitably viewed ‘through a theoretical lens that privileges power’.
Physicians’ attitudes have been identified as barriers to informed and shared decision making (ISDM) and a major barrier to the practice of ISDM by motivated physicians appears to be the need to change well established patterns of communication with patients (Towle et al 2006). Recent research in general practice has identified the importance of GPs eliciting the triad of ideas, concerns, and expectations (ICE) in the general practice consultation which has a potential impact on medication prescribing (Matthys et al 2009). These ICE components are highlighted as key competencies related to shared decision making, especially when deciding whether to prescribe medication. Additional expertise is required when that medication involves treatment for drug misuse.
There has however been little emphasis placed on any aspect of partnership or relationship building in general practice in the RoI. A recent qualitative study involving thirty Irish GP trainers highlighted the GPs relationship with what the investigators termed a ‘heart lift’ as opposed to the phrase ‘heart sink’ patient (O’Riordan et al 2008). Among questions posed to the GPs the question of Tell me about a patient you like? elicited three themes: easy to like, a challenge, and the necessity to renegotiate the doctorpatient relationship. When describing a lady in her 30’s who was prescribed methadone, one GP expressed the following; she was singularly the most difficult patient I’ve ever come across: their relationship had ‘deteriorated’ and she felt I
didn’t care. She’s the only person that has told me ...I really failed them. This led to an explicit renegotiation of the relationship: The patient stopped her drug misuse, she y’know is a delight.
When the GPs were also asked what have you learned about yourself as a GP? one theme elicited was the GPs role as a facilitator of sometimes chaotic and difficult lives. This study was not specifically aimed at GPs’ responses to drug misusing patients in its original intention however it does offer narratives which are useful for reflecting on the importance of the doctorpatient relationship with patients who challenge their assumptions. The authors addressed the limitations of the study claiming there was a risk of social desirability bias as the decision to restrict the study to trainers may have meant that a snapshot of an unusually reflective minority was gained, which may not have been reflected in the wider GP community. It is interesting that the assumption made by the medical profession regarding ‘’chaotic use’’ infers that chaos is constituted as selfevidently bad and the opposite of order and stability. The intrinsically ‘’chaotic user’’ has thus partially been defined by his or her inability to enact or inhabit stability. This view has been frequently accepted in drug misuse discourse and these attitudes have the potential to undermine relationship building. Fraser and Moore (2008) suggest that blanket assumptions such as these pose the risk of failing to grasp fully the dynamics of drug misuse, and importantly, some of the reasons why harm reduction measures are not always adopted by drug misusers. O’Riordan et al (2008) concluded that the process of relationship building can be enhanced by education and support such as reflective learning, teaching and training for all (Anderson et al 2003).
Understanding the significance of the doctor–patient relationship may be central to exploring who controls the intervention of MMT in general practice. Improving the doctorpatient relationship is challenging and fear and lack of expertise in how to deal with drug related problems can
affect this relationship. Fraser and Valentine (2008:19) describe how very privileged professionals have been traumatised by their experience of providing methadone treatment and they themselves have been subject to serious anxiety, possible danger and isolation in their work with service users. Neale (1999:143) recognized that social workers also, although familiar with working in partnership with other agencies, and trained to make connections between personal troubles and the broader social factors involved in client problems, sometimes feel that they do not have sufficient resources to deal with complex problems. Taking account of the broader family and social circumstances of the individual in a onetoone consultation is complex and meeting the needs of drug using parents and their children has been described as a formidable challenge (McKeganey et al 2002). In Dublin the rehabilitation process associated with drug addiction has been described as prolonged, raising many childcare issues for professionals (Quigley 2002). Effective and intuitive consultation is at the heart of good practice and the ability to engage in a facilitative rather than autocratic manner has been advocated in many models of consultation (Pendelton 1984, Neighbour 1987, Kurtz et al 1998). Treating drug misusers with respect, listening to their concerns and those of their families has been actively desired and highlighted by drug misusers themselves as crucial to their treatment (Fischer et al 2007).
Other issues which may arise in the consultation are those which involve change and the formation of identity. Drug misusers’ experiences of recovery from heroin addiction and the desire for a new identity and a different style of life were evident in a study carried out by McIntosh and McKeganey (2001). They conducted 70 semistructured interviews with recovering addicts in Scotland and these accounts consistently described a process of trying to recover or repair what they experienced as a ‘’spoiled identity’’ as a result of drug addiction. The
need for training in the area of identity formation and change was recognized in this study. It is true that few people make an immediate and onceonly transition from drug misuse to abstinence (McKeganey et al 2004). Redefining the ‘’sense of self’’ and reconstructing the identity of the recovering drug misuser has been identified as a process which requires experienced care (Etherington 2008). How that process of transition is facilitated in general practice and how users’ experiences of methadone treatment services influence individuation, recovery and the formation of identity has had limited research focus. It is uncertain what training is required to address this process of recovery in treatment from the perspective of the user. Mistral and Velleman (2001) surveyed GP’s in Wiltshire and suggested that carefully focused education, training and support could increase effectiveness for the service user on MMT. However this was only if the primary care practitioners were willing. Taking into account the service user's perspective might support identity formation leading to some improved outcome for the patient on MMT. Factors that impact on retention and therapeutic engagement such as the relationship between patient outcomes and elements of the therapeutic processnamely the treatment environment, patient needs, and delivery of services should be addressed in the consultation (Simpson et al 1997). While practical approaches to care are extremely important there are other aspects to the therapeutic relationship and patient participation which require negotiation with patients in relation to a range of issues (Haidet et al 2006). There is no doubt that therapeutic commitment is required when working with those addicted to drugs. What is regarded as therapeutic and a desirable result by the service provider may be viewed less favourably by the service user. Service user for the purpose of this study is defined as the individual who is receiving the intervention of methadone maintenance in the setting of general practice. Achieving a therapeutic effect may require a high degree of physician and patient negotiation and a process of
engagement with service users which has hitherto been noticeable by its absence.