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-Estrogen used in most COCs: Ethinyl estradiol
-Most available progestins have both progestogenic and androgenic activity
-Mechanism of action: Suppression of GnRH, pituitary gonadotropin secretion; Inhibition of the midcycle luteinizing hormone (LH) surge, preventing ovulation; making endometrium less suitable for implantation.
-Typical-use failure rate: 8 percent
-Hormonal contraception can be continued until the age of menopause (average age 50 to 51 years) in healthy, nonsmoking, normal-weight women
-COC use has been associated with increased risks of myocardial infarction, hypertension,stroke, increase risk of venous thromboembolism.
-Contraindications for COC initiation:
Migraines with aura
Age > 35 years
Known thrombogenic mutations
Ischemic heart disease or severe valvular heart disease
History of stroke
Current breast cancer
Liver cancer or cirrhosis
Non-Contraceptive Benefits of COCs: improves abnormal uterine bleeding, premenstrual syndrome, dysmenorrhea, painful ovarian cysts, acne, hirsutism, polycystic ovary syndrome,bone density, reduces the risk of endometrial and ovarian cancer;
Don’t Get Confused: COCs and Cancer: They increase the risk for developing cervical cancer; They reduce the risk of developing ovarian and endometrial cancers. Overall, the pill is not associated with an increased risk of cancer.
Initiation: COCs can be started anytime during the cycle after excluding the pregnancy.
Quick Start method: begin taking COCs on the day she is given the prescription.
Sunday Start method: start the pill on the first Sunday after her period
-Drugs which decrease the efficacy of a COC: Phenobarbital, Phenytoin,topiramate, primidone Griseofulvin, Rifampin
-Only antibiotic proven to decrease serum ethinyl estradiol and progestin levels in women taking COCs: Rifampin
Doctors in Belgium now euthanizing autistic individuals. Welcome to the new brave world where a psychiatrist can determine whether you are an individual worth living or should be killed for the greater good of the society. If we forget that God created us in His image, we are inevitably led to a utilitarian society like Belgium.
Screen all pregnant women at the first prenatal encounter with serologic testing.
But women at high risk of infection need rescreening at 28-32 weeks and at delivery.
Treatment: Penicillin G benzathine
Jarisch-Herxheimer reaction: An acute febrile reaction precipitated by the treatment of syphilis consisting of headache, myalgia, rash and hypotension. It is due to the release of large amounts of treponemal lipopolysaccharide from dying spirochetes. Counsel all patients about JHR. Management is supportive care with antipyretics and IV fluids.
Adverse pregnancy outcomes: Miscarriage, preterm birth, stillbirth, impaired fetal growth, congenital infection, neonatal mortality.
-Treponema pallidum infections the placenta (transplacental transmission to the fetus can occur around 9th to 10th week of gestation)
-Classic radiographic appearance of pneumonia in infants with congenital syphilis: Complete opacification of both lung fields (‘pneumonia alba’)
Genital Herpes Simplex in pregnancy: presents with painful genital ulcers, fever, dysuria, pruritis.
Diagnosis by finding vesicular or ulcerated lesions, PCR, viral culture
Treatment of primary infection: treat with acyclovir, valacyclovir, famciclovir
Treatment of recurrent infection: treat with antivirals only if there are prolonged and severe symptoms.
Suppressive therapy at 36 weeks: For all women with a genital HSV anytime during pregnancy, initiate suppressive therapy at 36 weeks until the onset of labor, use 400 mg three times daily.
Delivery: mostly vaginal delivery; C-section if there are active genital lesions or pain and burning
Cesarean delivery can decrease but not eliminate the risk of neonatal HSV infection
-Untreated bacteriuria has been associated with an increased risk of preterm birth, low birth weight, and perinatal mortality
-Most common pathogen: E.Coli
-Screen all pregnant women for asymptomatic bacteriuria at 12-16 weeks or the first prenatal visit with the culture of a urine specimen.
-Treat asymptomatic bacteriuria and cystitis: Nitrofurantoin (avoid use during the first trimester and at term), Amoxicillin, amoxicillin-clavulanate, cephalexin, cefpodoxime, Fosfomycin. -Trimethoprim-sulfamethoxazole: Avoid during the first trimester and at term; a folic acid antagonist, caused abnormal embryo development in animal studies.
-Avoid sulfonamides in the last days before delivery because they can displace bilirubin from plasma binding sites in the newborn, increasing the risk for kernicterus.
-Avoid aminoglycosides; they can cause ototoxicity.
-Do not use tetracyclines and fluoroquinolones
Pyelonephritis: presence of flank pain, nausea, vomiting, fever, costovertebral angle tenderness.
Treatment of pyelonephritis: Hospitalization with intravenous antibiotics and later oral antibiotics (ceftriaxone, cephalexin, cefazolin, ampicillin plus gentamicin)
Safe antibiotics throughout pregnancy: Penicillins, Cephalosporins, Aztreonam and Fosfomycin.
Human milk is recommended as the exclusive nutrient source for feeding term infants for the first six months of life and should be continued with the addition of solid foods after six months of age.
Benefits of Breastfeeding:
-Human milk stimulates gastrointestinal growth and motility.
-increases the rate of gastric emptying.
-increases the intestinal lactase activity.
-inhibits microbial activity.
-improves visual function
-lowers the incidence of gastroenteritis and respiratory disease, otitis media, urinary tract infection, sepsis
-prevents overweight and obesity.
-reduces the risk of cancer, heart disease, allergic conditions, diabetes
-improves cognitive development
-promotos stress reduction
Common Problems of Breastfeeding
Inadequate milk production
Poor milk extraction
Improper breastfeeding techniques
Nipple and Breast pain (treat with bacitracin or mupirocin, acetaminophen, ibuprofen, antifungals)
Infants with ankyloglossia (treat with lingual frenotomy)
Nipple vasoconstriction (treat with nifedipine, a vasodilator)
Engorgement (apply warm compresses, ibuprofen, acetaminophen, milk removal)
Plugged ducts (learn correct positions and latch techniques, empty the breast with frequent feeds, acetaminophen, ibuprofen, ultrasound to rule out an abscess
Lactational mastitis: anti-inflammatories, antibiotics (No MRSA risk: dicloxacillin, cephalexin, clindamycin; MRSA risk: use trimethoprim-sulfamethoxazole, clindamycin, linezolid)
Galactoceles: can occur due to unrelieved plugged ducts, need aspiration.
-Collapse of the uterine fundus into the endometrial cavity turning the uterus partially or completely inside out.
-A rare complication of vaginal delivery
-An obstetrical emergency.
-If not promptly recognized and treated, uterine inversion can lead to severe hemorrhage and shock
-The most common disorder in differential diagnosis: Prolapsed fibroid
-Key finding: On abdominal examination, lack of palpation of a normally positioned fundus.
-Ultrasound, CT, MRI
-Treatment: Manage postpartum hemorrhage and shock, if present using volume resuscitation, blood transfusion, Discontinue uterotonic drugs (oxytocin), give uterine relaxants (nitroglycerin,Terbutaline, Sevoflurane, Desflurane, Isoflurane), do not remove the placenta, immediately attempt to manually replace the inverted uterus to its normal position, Place a hand inside the vagina and push the fundus along the long axis of the vagina toward the umbilicus (Johnson maneuver). If these measures fail, consider surgery (Huntington procedure, Haultain procedure)
-Postpartum hemorrhage is a condition in which a woman loses a very large amount of blood after childbirth.
-An obstetric emergency.
-Key features: (1) cumulative blood loss ≥1000 mL or (2) bleeding associated with signs/symptoms of hypovolemia within 24 hours of the birth process regardless of delivery route.
-The most common cause of PPH: Uterine atony
-Risk factors: trauma, retained placenta, membranes, failure to progress during the second stage of labor, lacerations, instrumental delivery, macrosomy, preeclampsia, eclampsia, HELLP syndrome, induction of labor, placental abruption, placenta previa, acquired or congenital coagulation defects.
-Prophylactic use of oxytocin during labor reduces the risk of PPH.
Clinical: Tachypnea, tachycardia, hypotension, low oxygen saturation, and air hunger are signs of hypovolemia due to hemorrhage
Labs:Complete blood count, Prothrombin time, activated partial thromboplastin time, fibrinogen level, HCG, Thromboelastography (TEG) and rotational thromboelastometry (ROTEM), where available; Ultrasound, CT, MRI
-Treatment: Volume resuscitation, blood transfusion, Coagulopathy is treated medically, with transfusion of blood and blood products.
-Treat the cause of bleeding (manage atony, repair lacerations, remove any retained placental fragments, manually replace an inverted uterus if present, hysterectomy if there is uterine rupture.
Surgical: dilation and curettage, suction curettage, arterial embolization,Ligation of the uterine and utero-ovarian arteries. intrauterine balloon tamponade, pelvic packing, laparotomy,Hysterectomy in resistant cases
-Hyperfibrinolysis and fibrinogen depletion are common in the early stages of bleeding. Therefore, an early administration of tranexamic acid, an anti-fibrinolytic drug, can reduce death due to bleeding in women with postpartum hemorrhage related to atony or trauma.
-Tranexamic acid should not be mixed with blood or given through a line with blood, or mixed with solutions containing penicillin.
-Intra-amniotic infection (IAI, chorioamnionitis) is the infection of the amniotic fluid, membranes, placenta, umbilical cord, and/or decidua.
-The key criterion: Maternal fever
-The diagnosis of IAI is based on clinical findings: maternal fever, Baseline fetal heart rate >160 beats/min for ≥10 minutes, Maternal white cell count >15,000/mm³ , Purulent-appearing fluid coming from the cervical os visualized by speculum examination, positive Gram stain of amniotic fluid, Low glucose level in amniotic fluid, Positive amniotic fluid culture, High white cell (WBC) count in amniotic fluid, Histopathologic evidence of infection or inflammation or both in the placenta, fetal membranes, or the umbilical cord vessels
-Laboratory studies should be performed on amniotic fluid obtained by amniocentesis.
-Treatment: Antibiotics + Delivery. Treat with broad-spectrum antibiotics: ampicillin, gentamicin, ticarcillin-clavulanate, cefoxitin, cefotetan, piperacillin-tazobactam, ertapenem, vancomycin, clindamycin; Monitor fetus during delivery.
-Complications: perinatal death, asphyxia, early-onset neonatal sepsis, septic shock, pneumonia, meningitis, intraventricular hemorrhage, cerebral white matter damage, and long-term neurodevelopmental disability including cerebral palsy
-Endometritis is the inflammation and infection of the inner lining of the uterus.
-Postpartum endometritis is defined as an oral temperature of ≥38.0 °C [≥100.4 °F] or more on any 2 of the first 10 days postpartum, exclusive of the first 24 hours).
-The most common cause of infection after childbirth.
-The most important risk factor for development of postpartum endometritis: C-section
-Diagnosis depends on clinical criteria: postpartum woman with fever, uterine tenderness, foul lochia, chills, lower abdominal pain
-Labs may show a rising neutrophil count, elevated bands, but don’t rely on them.
-Treatment: Broad spectrum antibiotics: Clindamycin, gentamicin, ampicillin-sulbactam, vancomycin
Group B Streptococcal infection is a gram-positive coccus infection which is an important cause of illness in infants, pregnant women
-It is a frequent cause of asymptomatic bacteriuria, urinary tract infection, upper genital tract infection (ie, intraamniotic infection or chorioamnionitis), postpartum endometritis, pneumonia, puerperal sepsis, and bacteremia without a focus.
-Asymptomatic bacteriuria is identified by screening urine cultures that are obtained during prenatal visits. At least one screening urine culture should be obtained during early pregnancy.
-Invasive maternal infection with GBS is associated with pregnancy loss and preterm delivery.
-Colonization of pregnant women by GBS is a major risk factor for neonatal GBS infection.
-Sterile urine must be documented after treatment, and periodic screening cultures should be obtained throughout the pregnancy to identify recurrent bacteriuria.
-Women with documented GBS bacteriuria should not be screened for GBS rectal/vaginal colonization later in pregnancy but should be considered persistently GBS colonized and receive intrapartum chemoprophylaxis at the time of delivery.
-Perform universal screening at 35 to 37 weeks.
-Women with any GBS bacteriuria should receive intrapartum chemoprophylaxis at the time of delivery to prevent neonatal infection
-Treat with antibiotics: Amoxicillin, penicillin, cephalexin, clindamycin
-Gestational diabetes mellitus develops during pregnancy in women whose pancreatic function is insufficient to overcome the insulin resistance associated with the pregnant state.
-Identifying pregnant women with gestational diabetes mellitus followed by appropriate therapy can decrease fetal and maternal morbidity, particularly macrosomia, shoulder dystocia, and preeclampsia.
Two-step screening test: Screen everyone at 24 to 28 weeks; The first step is a 50-gram one-hour glucose challenge test (GCT). Positive patients go on to the second step, a 100-gram, three-hour oral glucose tolerance test (GTT), which is the diagnostic test for gestational diabetes mellitus.
-Adverse outcomes associated with gestational diabetes: Preeclampsia, gestational hypertension, hydramnios, macrosomia, maternal and infant birth trauma, operative delivery (cesarean, instrumental), perinatal mortality, Fetal/neonatal hypertrophic cardiomyopathy, neonatal respiratory problems and metabolic complications (hypoglycemia, hyperbilirubinemia, hypocalcemia, polycythemia)
-Long-term, women with gestational diabetes mellitus are at increased risk of developing type 2 diabetes as well as type 1 diabetes and cardiovascular disease.
-A diagnosis of overt diabetes is made when A1C is ≥6.5 percent.
-Nutritional therapy, Glucose monitoring, target fasting blood glucose <95 mg/dl; insulin, selected oral antihyperglycemic agents (metformin, glyburide)
A single third trimester ultrasound to screen for macrosomia.
Scheduled cesarean delivery to avoid birth trauma is typically offered to women with GDM and estimated fetal weight ≥4500 grams.
-All women with GDM should have a two-hour, 75-gram oral glucose tolerance test between 6 and 12 weeks postpartum
-Placental abruption (also referred to as abruptio placentae) refers to partial or complete placental detachment prior to delivery of the fetus.
-The immediate cause is rupture of maternal blood vessels in the decidua basalis.
-Risk factors: previous abruption, cocaine use, smoking, hypertension, uterine anomalies,
-Classic Symptoms and Signs: vaginal bleeding, abdominal pain, contractions, uterine tenderness, a nonreassuring fetal heart rate (FHR) tracing
-Severe abruption can lead to Disseminated Intravascular Coagulation (DIC).
-Classic Ultrasound Finding: Identification of a Retroplacental Hematoma/blood clot.
Fetal heart rate nonreassuring, vaginal delivery or C-section.
Fetal heart rate is reassuring but mother unstable: vaginal delivery or C-section.
Mother & Fetus stable, less than 34 weeks gestation: conservative management
Mother & Fetus stable, at 34 – 36 weeks gestation: delivery
-One to 6 percent pregnant women presents with ultrasound evidence of a placenta previa between 10 and 20 weeks of gestation. 90 percent of these early cases resolve.
-The characteristic symptom: Painless vaginal bleeding.
-Major risk factors: Previous placenta previa, previous cesarean delivery, multiple gestation, increasing maternal age, increasing parity, maternal smoking, cocaine use, infertility treatment.
-Placenta previa should be suspected in any woman beyond 20 weeks of gestation who presents with vaginal bleeding.
-Diagnosis is based on identification of placental tissue over the internal cervical os on ultrasound.
-Asymptomatic women: determine whether the previa resolves with increasing gestational age. Follow-up transvaginal ultrasonography is performed at 32 weeks of gestation and again at 36 weeks if the placenta remains over or <2 cm from the internal os
-If previa persists at 36+0 to 37+6 weeks of gestation, perform cesarean delivery.
-An ectopic pregnancy is an extrauterine pregnancy. Almost all ectopic pregnancies occur in the fallopian tube (96 percent), but other possible sites include cervical, interstitial, hysterotomy (cesarean) scar, ovarian, or abdominal.
-Most common symptoms: Abdominal pain and vaginal bleeding
-Evaluate with Transvaginal Ultrasound (TVUS) and quantitative hCG level. Measure hCG serially every two to three days.
-The diagnosis of ectopic pregnancy is a clinical diagnosis made based upon serial hCG testing and TVUS
-Do not depend on a single hCG result to diagnose ectopic pregnancy.
-hCG discriminatory zone: It is the serum hCG level above which a gestational sac should be visualized by Ultrasound if an intrauterine pregnancy is present. It is around 2000 IU/Liter.
-If the serial hCG is rising abnormally and is below the discriminatory zone, the diagnosis is made based upon hCG levels.
-If the hCG is above the discriminatory zone, the diagnosis is made using ultrasound findings (gestational sac with a yolk sac or embryo)
Eating while watching TV is a bad habit
Mayo Clinic Diet Journal recommends that we should break 5 habits to lose weight effectively.
››Alcohol counts as a sugar, so avoid it to decrease calorie intake, at least in the Lose It! phase. Also stay away from artificial sweeteners during this phase because they may increase your cravings for sweets.
››You can reduce your intake of added sugar and artificial sweeteners in many different ways. For example, drink unflavored, carbonated water. In baking, try substituting a fruit puree, applesauce, or something similar for sugar.
3. No snacks, except for vegetables and fruits. The snacks that people often eat are not that healthy, high in calories, and difficult to stop eating. That means the calorie intake from snack foods can be very high. Vegetables and fruits should be the main snacks to consume, but a small amount of nuts could be a good choice if you crave a more traditional snack.
4. Moderate meat intake and use low-fat dairy. Meat is associated with increased calorie intake, weight gain, and poorer overall health. From a health standpoint, less is better when it comes to red meat, and especially processed meat.
Low-fat dairy contains the same nutrients as full-fat dairy except for the fat content, and the saturated fat in full-fat dairy just adds extra calories and contributes to increased cholesterol levels.
DID YOU KNOW?
In the United States, a large amount of sugar has been added to the food supply. Sugar has been shown to contribute to increased calorie intake and increased weight.
Try to eat just one serving—about the size of a deck of cards—of meat daily. Eating less meat increases the opportunities to eat a wide variety of other foods, such as whole grains, pasta, fish, vegetables, or tofu.
5. No eating at restaurants unless the meal fits the program. When people eat out, they’re not in control of what they’re eating. Many of the dishes served in restaurants may taste good, but they may also be very high in calories. It can be hard to know since you’re not in charge of portion size or cooking techniques.
If you can find things on a restaurant menu that fit the overall program, that’s okay, but be careful when eating at restaurants while losing weight. Research shows that eating out is one of the factors associated with increased calorie intake and increased weight.
When you do eat out, keep in mind that restaurants are often willing to change recipes or modify them to your needs. Don’t be afraid to ask restaurants to change the way a food is prepared or the amount that’s served.
Mayo Clinic Diet recommends to add five habits to lose weight. Today, let us understand, and hopefully, implement them in our daily lives.
Don’t indulge in dried fruits and fruit juice too much. Those are more concentrated sources of calories.
3. Eat whole-grain carbohydrates, such as brown rice, oatmeal, whole-wheat bread, or whole-grain pasta. This habit is both for health and for weight reasons. From a weight standpoint, whole grains contain fiber; therefore, they’re bulkier. This can contribute to satiety, or the feeling of fullness. Whole grains are lower in energy density than refined grains.
You can do many things to increase your intake of whole grains, such as swapping whole-wheat bread or pasta for the regular versions.
DID YOU KNOW?
Studies have shown that people who eat more vegetables and fruits tend to weigh less and gain less weight over time.
DID YOU KNOW?
Studies have shown that people who eat a diet that’s higher in fiber tend to weigh a little bit less over time.
5. Move. Try to walk or do some other type of physical activity or exercise for 30 minutes or more each day. If you’re not very active, you may want to build up to this. Start slowly and gradually work up to 30 minutes, and certainly don’t overdo it. Talk to your health-care team before starting a physical activity program.
Don’t do something that is painful or not enjoyable. Instead, try to work regular physical activity into your everyday life. Throughout the day, take the stairs, for example. You can even chunk up the time by walking the stairs for 10 minutes at a time. Or schedule your exercise session if it helps you to do that.
It’s human nature to want to decrease physical activity and take the shortcut. But our environment has markedly changed since the days when those who ate the most and did the least survived. These days, we have to outsmart our inner brain and look for opportunities to get activity.
There are simple ways to do this. Park farther away from your destination. Look for excuses to get more physical activity. Try games and apps that promote physical activity if they interest you.
If you’re going to exercise, choose something you enjoy, make it a priority in your schedule, and focus on continuing it in the long term. Don’t do something that you can’t keep up in the long term or take on too much too fast.
Often in life, something comes along and knocks your exercise off schedule. If this happens, one option is to change the time around: Sometimes exercise in the morning, sometimes at noon, and sometimes in the evening.
Reference: Mayo Clinic Diet Journal
In Chicago’s Mercy Hospital, a gunman killed Dr.Tamara O’Neal right in the hospital along with a pharmacist and a young police officer.
The doctor’s offense was she cancelled off her wedding plans with the shooter.
Gone are the days when hospitals enjoyed a sacred status where guns are not allowed. For the modern man nothing is sacred including human life.
Health care should be delivered with cross-cultural sensitivities. The quality of healthcare improves when doctors understand sociocultural differences between themselves and their patients.
DEFINING CULTURE — Culture is a system of beliefs, values, rules, and customs that is shared by a group and is used to interpret experiences and direct patterns of behavior. Culture plays a large role in shaping each individual’s health-related values, beliefs, and behaviors, and clearly impacts clinical care.
When a clinician interacts with a patient, three cultures are juxtaposed: the patient’s, the clinician’s, and the culture of medicine. All three cultures influence the outcome of the encounter. To understand patients, it is first necessary to recognize our own cultural beliefs, values, and behaviors, as well as personal life experiences that have influenced the way we think about health care and make clinical decisions. In addition, the culture of medicine has its own particular beliefs, values, and customs (eg, the idea of patient autonomy and the value placed on scientific evidence). Finally, the patient’s social and cultural background affect the quality of understanding and communication that occurs in the clinical encounter.
The core values necessary for providing effective cross-cultural care are values fundamental to the practice of medicine: empathy, curiosity, and respect.
Clinicians increasingly see patients who may hold beliefs and values that differ from their own .
Effective communication — Effective clinician-patient communication is directly linked to improved patient satisfaction, adherence, and, subsequently, health outcomes. However, patients, particularly those from minority backgrounds, are often dissatisfied with their ability to communicate with their clinician.
Racial and ethnic disparities in health care —
●African Americans are less likely than non-Hispanic whites to be referred for cardiac catheterization for coronary artery disease.
●Hispanics with isolated long bone fractures were twice as likely as non-Hispanic whites to receive no pain medication in the emergency department, in a study from one US academic medical center. Despite an increase in the past decade in opioid use for pain-related diagnoses visits in US emergency departments, disparity in pain treatment between ethnic groups has not decreased. Compared with white patients, the odds ratios for black, Hispanic, or Asian patients to receive opioid treatment were 0.66, 0.67, and 0.79 respectively.
●The risk of an African American developing end-stage renal disease requiring dialysis is four times greater than a European American. Once on dialysis, African-American patients are only 70 percent as likely to be referred for evaluation for renal transplantation.
●African Americans with hyperlipidemia, compared with non-Hispanic whites, are less likely to achieve target lipid levels, less likely to be using medication to control lipids, and less likely to be taking high efficacy statin drugs.
●Asian Americans, compared with non-Hispanic whites, have lower rates of cancer screening (colorectal and breast), adjusting for access to care and socioeconomic status. Foreign-born Asians, on survey, believed that cancer screening should be a response to symptoms and declined tests because of lack of symptoms.
●Minorities in the United States are less likely to seek mental health treatment when indicated than are white Americans; mental health providers (psychiatrists, psychologists, and social workers) are less likely than general medical practitioners to be Hispanic, black, Asian, or Native American.
Skills for cross-cultural care — Cross-cultural care is based on universal principles of patient-centered care.
Components of cross-cultural care include effective use of interpreters, familiarity with differences in disease epidemiology, and comfort level in working with patients who are culturally different than oneself. Additionally, cross-cultural care goes beyond learning about patients based on their racial, ethnic, or cultural background, to focusing on the skills required to follow the principles of patient-centered care.
Patient-centeredness encompasses qualities of compassion, empathy, and responsiveness to the needs, values, and expressed preferences of the individual patient. Cross-cultural care aims to take this a step further to include skills that are especially useful in cross-cultural interactions but remain vital to all clinical encounters.
Styles of communication — Differences in styles of communication between patient and clinician, which can lead to discomfort and miscommunication, include both verbal and non-verbal communication: eye contact, touch, and personal space. Direct eye contact may be avoided in some cultures, while in others it is a sign of respect. Providers should be aware of their own tendencies and should be sensitive to the preferences of their patients.
Techniques for adapting to different communication styles and customs are as follows:
●Get a sense for the patient’s general communication style and adapt your style of communicating to fit best with his or hers.
●Try to draw out indirect or reserved patients by making them feel comfortable and asking open-ended questions. Do not assume that lack of resistance means agreement with your plan or recommendations.
●Determine how the patient prefers to receive information about results of testing.
•”I am going to check the report of your sonogram tomorrow and would like to let you know the results. Some of my patients want to be told directly, no matter what the test shows, even over the phone. While I don’t suspect that there will be anything serious, I would like to know how you prefer to hear the results.”
●Get a sense for whether the patient is more stoic or expressive of pain and symptoms. Avoid judging patients based on your own cultural perspective.
●Pay attention to cultural differences in personal space, eye contact, body language. Try to be flexible, and not to be misled by misinterpretation of communication cues.
Trust — Trust is a crucial element in the therapeutic alliance between patient and health care provider. It correlates directly with adherence to clinician recommendations and patient satisfaction. Mistrust of the health care system also affects patient’s use of services and results in inconsistent care, doctor shopping, self-medicating, and an increased demand for referrals and diagnostic tests by patients.
The provider should be aware of cues that may indicate some degree of mistrust. Patients may express concerns about whether a particular test is necessary, or they may mention a bad experience in the past. These should lead to direct efforts at reassurance and trust-building. Suggestions for building trust with patients, especially across cultures, include:
●Discuss mistrust openly. If the patient seems open to it, discuss why they might feel mistrustful of doctors or medical care. Reassure them of your intentions to help.
•”You’ve mentioned that you don’t really like coming to doctors. Was there anything in particular that led you to feel that way? (Any bad experiences or concerns?)”
●Explore the patient’s perspective. Ask what’s important for him or her.
•”What are your thoughts about having this operation?”
•”What were you hoping that I could do for you today?”
●Provide focused reassurance. After determining the patient’s perspective and concerns, focus reassurance on those concerns.
•”You’ve told me that the pain is what you’re really worried about so I’m going to make absolutely sure that you’ll have enough pain medication after the operation.”
●Build a partnership. Many mistrustful patients respond well to being given options and some control over their health care decisions.
●Communicate clearly. Listen carefully, avoid medical jargon, and check in regularly for feedback from the patient.
Techniques for understanding cultural differences in decision-making and family dynamics include:
●Introduce yourself respectfully to the patient and others in the room and determine their relation to the patient, keeping in mind that in some cultures it is appropriate to speak only to certain individuals.
●Find out if the patient prefers autonomy or would want the family, or someone in particular, to be involved in medical decision-making.
•”How much do you want your family to be involved in making decisions regarding your health care (such as tests or medications)?”
●Find out if there is an authority figure in the family, community, or religious group to consult and involve in important decisions.
•”Is there anyone in particular whom we should talk to about your health care besides you, someone who makes decisions in your family (or community)?”
●Consider allowing a patient to waive their right to know (legal documents can be signed in this case) when the family wants to withhold information.
●When a dominant family member is not allowing direct communication with the patient, explain the situation tactfully. If this fails, try ways to obtain information directly from the patient without offending the relative. However, if there is any concern for domestic abuse, laws protecting the patient should supersede issues of cultural sensitivity.
•”I appreciate what you’re saying, Mr./Ms. ——, your input is very important. From a medical standpoint, though, it’s also very important for me to hear a description of the problem from the patient herself, so I can make a more accurate diagnosis.”
●Realize that in many cultures it is typical (and important) for family members (as many as 5 or 10) to stay with the patient in the hospital at all times. If this leads to difficulty for the staff, it should be negotiated openly.
Many of these health-based traditions and customs are directly related to the patient’s worldview, religion, or spiritual beliefs. Illness and death are among the most powerful and mysterious phenomena in our existence, and people often seek meaning in these experiences through spirituality. Clinicians may undervalue the importance of addressing spiritual concerns with patients in the primary care setting. Patient expressions of spirituality should be discussed when appropriate and relevant to the clinical interaction.
Questions for clinicians about customs, religion, and spirituality include:
●Can you tell me anything about your customs that might affect your health care? What about your diet?
●How important is religion (or spirituality) in your life?
●How important are these beliefs to you, and do they influence how you care for yourself or what type of care you might receive?
Techniques for understanding sexual and gender issues, customs, and taboos include:
●Be aware of the different ways that patients and families view gender roles and try to accommodate them when feasible.
•”Unfortunately, we have no female obstetricians in clinic today, but if you are willing to reschedule your appointment, I can make sure that your wife will see a female doctor next week.”
●A judgmental attitude toward patients is unlikely to change behaviors and values, but may compromise the clinician-patient relationship and the ability to provide good health care.
●Ask patients/family what is acceptable to them, rather than making assumptions based on limited information (name, clothing, etc).
•”I perform breast examinations on all of my female patients to look for signs of breast cancer or other problems. Is this okay with you?”
●Be particularly sensitive to patients’ views on discussing sexual issues openly. State that you will be asking about some personal issues and explain why, especially in interactions where you are unfamiliar with the patient’s cultural background.
•”I generally ask all patients about some very personal matters at this point, which are important for doctors to know about. Are you comfortable talking about these things with me?”
●Recognize that patients’ views and language regarding sexuality and sexual orientation may differ. Ask whether patients have had sexual partners who are men or women rather than whether they are gay, bisexual, etc.
●Be open to and learn appropriate terminology for patients whose gender identity does not fit into the traditional male or female categories.
There is individual variation in how tightly people adhere to their beliefs. Some will be happy to learn “the truth” from a clinician. Others will ignore whatever they are told if it doesn’t take into account their own particular perspective and respect their common sense.
Techniques to understand the patients use of complementary/alternative medicine include:
●Ask patients in a non-judgmental, open-minded way about non-medical, alternative practices (can be asked after “medications” in the medical history).
•”A lot of my patients use other forms of treatment, like home remedies, herbs, or acupuncture, that can be helpful. Besides the medications that you mentioned, have you used any other types of therapy?”
●Check to see whether alternative therapies are safe and look for any interactions with medications.
●Negotiate the use of alternative therapies along with standard medicine when safe and important to the patient, and discuss reasons to discontinue any dangerous ones.
Questions regarding environment change include:
●Where are you from originally? When did you come and why did you decide to come?
●How have you found life here compared with life in your country (city, town)?
●What was medical care like there compared with here?
The following are some basic tips for working with interpreter services:
●Introduce the interpreter to patient
●Position the patient, interpreter, and yourself in triangle so each can see each other’s face
●Address and make eye contact with the patient, not the interpreter
●Ask one question or express one idea at a time and keep phrases short
●Encourage the interpreter to clarify terms with you and confirm understanding and agreement with the patient
●Empower team members (including the interpreter) to speak up when they notice a communication problem
●It is your responsibility to ensure that the medical interpreter and patient understand what is being communicated – avoid medical jargon, idiomatic expressions, and acronyms
●How well do you speak English: Not at all, not well, well, or very well?
If the patient responds “not at all” or “not well,” an interpreter is appropriate; if the response is “very well,” interpretation is not necessary; if the response is “well,” a second question should be asked:
●In what language do you prefer to receive your medical care?
Questions that may be asked to evaluate literacy include:
●Do you have trouble reading your medication bottles, instructions, or other patient information?
●Do you have trouble with reading in general?
Social stressors and supports, also described as social determinants of health, may have strong impact on a patient’s illness experience. A socially isolated patient may manifest more symptomatology related to a given illness than a patient with a broader set of social supports.
Questions helpful to gain understanding of issues related to life control, social stressors and supports include:
●What is causing the most stress in your life? How do you deal with this (ie, family, friends, activities, religion)?
●Do you ever feel that you’re not able to afford food, medications, or other medical expenses?
●Do you feel that you have the ability to affect your own health (or particular medical condition) or is it out of your control?
The following steps are helpful in the negotiation process:
●Step 1: Explore the patient’s perspective – Ask open-ended questions about the patient’s understanding and concerns about the illness and its treatment.
●Step 2: Explain your perspective – Provide the patient with an explanation in terms that are understandable and familiar, sharing what you hope will be beneficial for them if they follow your recommendations.
●Step 3: Acknowledge the difference in opinion – Do this in a way that is non-judgmental and accepting of difference.
●Step 4: Create common ground – This may mean offering a compromise or asking the patient what they are willing to do. This often requires some back and forth discussion in an environment where the patient feels they can be open.
●Step 5: Settle on a mutually acceptable plan – Once a plan is developed, check in with the patient again to make sure that it is acceptable. Look for any sign of hesitation on the part of the patient and discuss this openly. Ensure that the patient understands and has retained the plan that has been negotiated and articulated by the provider in language that is plain, simple, and understandable to the patient.
If conflict remains after initial negotiation, it may be helpful, if the patient is willing, to involve other individuals who the patient trusts. When a mutually agreeable plan or understanding cannot be reached with a competent adult patient, it is important to document the negotiation process in the medical record and acknowledge that the patient has the ultimate decision in his or her health care.
IMMUNIZATION — The Centers for Disease Control and Prevention (CDC) makes annual recommendations for immunizations in adults.
●Influenza vaccine – We recommend annual influenza vaccination for all adults.
●Tetanus, diphtheria, and acellular pertussis vaccination (Td/Tdap) – The CDC recommends a single dose of Tdap in place of Td for all adults aged 19 years and older who have not received Tdap previously. Adults should receive a Td booster every 10 years.
●Varicella vaccine – We recommend routine varicella vaccination for healthy persons >13 years of age without evidence of immunity.
●Human papillomavirus vaccines – We recommend human papillomavirus vaccine (HPV) for females up to age 26 years who have not been previously vaccinated, for males up to age 21 who have not been previously vaccinated, and for men who have sex with men up to age 26.
●Zoster vaccine – We suggest zoster vaccination in most individuals who are 50 years of age or older.
●Pneumococcal vaccines – We recommend pneumococcal vaccination for all adults 19 to 64 years who have a condition that increases the risk of pneumococcal disease. It is also recommended for all adults ≥65 years.
●Meningococcal vaccines – We recommend Meningococcal vaccination for all young adults especially college students who dwell in the dorms.
●Hepatitis B vaccination – Patients at high risk for hepatitis B virus (HBV) should be vaccinated, including diabetic adults <60 years. For diabetic patients ≥60 years, vaccination may be warranted based on likelihood of acquiring hepatitis B and immune response.
If you need more information on vaccinations, please visit us to consult Dr.Paul Kattupalli or call us 814 424 2095.