CLINICAL TECHNIQUES

Values in Medical Practice

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 CLINICAL TECHNIQUES

Medicine as a Career ??

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CLINICAL TECHNIQUES
 Your Mother is sick. What four
Characteristics would you want
the doctor attending to your
Mother to have?? Write them
down in Priority order

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TRAINING OUTCOMES

•Knowledge?

•Skills?

•Attitude?
 VALUES

Values Behaviours
Internal External
 VALUES

Why are values so important?

How do we discover what values are held by a person,
institution or society holds?
Where do these values come from and the purpose they
serve?
Can values be taught, attitudes changed and behaviour
altered?
Observable behaviours, practices and discourse
‘the way we do things here’

Beliefs, attitudes, values, philosophies

‘why we do the things we do here’
In every 1,000 sick patients in developed countries
1000 persons

800 report symptoms

327 consider seeking medical care

217 visit a physician's office (113 visit a
primary care physician's office)
65 visit a complementary or
alternative medical care provider
21 visit a hospital outpatient clinic
14 receive home health care
13 visit an emergency department
8 are hospitalized
<1 is hospitalized in an
academic medical center
This is even more skewed in the developing world.
N Engl J Med, Vol. 344, No. 26 – June 28, 2001 – www.nejm.org 8
Key principles of health care delivery
 Health services delivered uses basic set of
principles
 Guided by Primary Health Care approach:-
Health care should be aligned to Communities
needs

 Forms the basis against which planning,

service provision, and monitoring should
be done
Guiding Principles
 Intermidiate Health Outcomes
1.Access to services
2.Quality of care, and service delivery
3.Patient safety
4.Coverage with service

Final Health Outcomes/Goals

1. Equity in outcomes

2. Efficiency of service delivery

3. Effectiveness of health care delivery

4. Ethics, and rights based approach in delivery of services

5. Sustainability of services
Intermidiate Health
Outcomes
1.Access to services
2.Coverage with services
3.Quality of care, and service delivery
4.Patient safety
Access
 Health care services should be unrestricted by
geographic, economic, social, cultural,
organizational, or linguistic barriers; for
high utilization.
Access addressess:-
 Ability of a person/community to receive health
care services
 The capacity, and factors influencing the entry into,
or use of the health care system.
 Describes the fit between the potential client, and
the health system.
Contd..’
The access dimensions include:
 accessibility,

 affordability,

 availability,

 adequacy and

 acceptability.
COVERAGE
Coverage of Health Services
 Encompasses aspects of improving the range
of services, and the population that is able to
benefit from the services.
 Measures the level of utilization of the
available health services.
 Focus is on extending the defined package of
services into more population groups.
 Measurement depends on: the level attained
(number of clients receiving the defined
service), and the equality of distribution
(persons receive the service based on their
need).
QUALITY OF CARE, AND OF
SERVICE DELIVERY
 Quality of health services
 Quality is defined as conforming to the
requirements’, ‘Fitness for use’ (Juran,
1988).
 The degree of quality is a measure of the
extent to which the care provided is
expected to achieve the most favorable
balance between the risks and benefits.
 Based on its characteristics a service can
be categorized into three, namely:
Structure, Process and Outcome
PATIENT SAFETY
Safety of Health Services
 Definition: Safety is a principle that aims
to ensure the care provided does not
become a cause of ill health.
 The WHO estimates that health care errors
affect 1 in 10 patients worldwide.
 Patient safety aims to limit/eliminate
preventable adverse effects of care,
whether or not these are evident or
harmful to the patient.
 Final Health
Outcomes/Goals
1. Equity in outcomes
2. Efficiency of service delivery
3. Effectiveness of health care delivery
4. Ethics, and rights based approach in
delivery of services
5. Sustainability of services

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 Equity of health care

 Definition: The absence of systematic

disparities in health (or in the major social
determinants of health) between social
groups who have different levels of
underlying social advantage/disadvantage
—that is, different positions in a social
hierarchy
Contd..
 Equity ensures that all inhabitants of a district
should not only have equal access to health
services, but also use them equally for equal need.
 Important determinants are geographical,
demographic (age and gender), socio-cultural
features, and economic.
 Inequities in health systematically put groups of
people who are already socially disadvantaged at
further disadvantage with respect to their health.
EFFICIENCY

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 Efficiency
 Ensures we are spending the least amount to generate the
desired health outputs
 OR we are generating the maximum amount of health outputs,
with available funds

 Important, as it ensures the health system is producing health

services, in the quantities and qualities that society wants
(allocative efficiency), and producing it at the lowest possible
cost (technical efficiency).

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EFFECTIVENESS
Effectiveness
 Measure of how well an intervention restores the
individual, to as near his prior healthy state as
possible

 Measured by comparing the situation before, and

after the intervention

 Actual outcome of the interventions (health state)

usually difficult to ascertain, so intermediate
outcomes usually used
 Such as, malaria cases averted, TB treatment
completion rates, children vaccinated, etc
Contd..
 Aims to ensure that the interventions we
prioritize are the ones that give our clients
the best possible health outcomes.
 Intervention should be able to restore the
health of the client to as near normal a
position as is feasible.
 Effective Interventions are ones that would
achieve the best health outcome at the lowest
cost
CLIENT CENTREDNESS:
RIGHTS BASED APPROACH
Principles of human rights approach

 Human rights are indivisible, universal and

interdependent. Claim-holders have a right
and are entitled to claim that right from
those that have the duty to implement it
(duty-bearers).
 The claim-holders should hold the duty-
bearers accountable for the realization of
the right – in this case, access to health
care.
Ethics in health
 Ethics based approach aims to apply
moral values and judgments as they apply
to health care.
 These are monitored, and managed
through the various councils
 Ethics aims to ensure that the aim of
health care is “to do good to others, and
have them, and society, benefit from this”,
and not “to do good, and benefit from it".
It is based on values of:
Ethics cont’
 Autonomy
 Beneficence (doing good)
 Non-Maleficence (doing no harm)
 Double effect
 Autonomy: During a patient’s illness
the level of autonomy is an indicator for
both personal well-being, and for the
well-being of the profession.
Ethics cont’
 Ethics tries to find a beneficial balance
between the activities of the individual
and its effects on a collective.
Ethics cont’
 Beneficence (doing good): Healing should be
the sole purpose of medicine, and any actions
beyond this are not considered part of the care
process.
 Non-Maleficence (doing no harm): Implies
maintenance of patient safety even when providing
treatments that carry some risk of harm.
 In desperate situations where the outcome without
treatment will be grave, risky treatments that stand
a high chance of harming the patient will be
justified, as the risk of not treating is also very
likely to do harm
Non-Maleficence (doing no
harm) cont’:
 So the principle of non-malfeasance is
not absolute, and must be balanced
against the principle of beneficence
(doing well).
 "Non-malfeasance" is also defined by its
cultural context, as each has its own
cultural collective definitions of 'good'
and 'evil'.
Double effect:
 Some interventions can create a positive
outcome while foreseeable, but
unintentionally, doing harm.
 The combination of these two
circumstances is known as the "double
effect".
 An example is the use of morphine in the
dying patient, which eases pain, while
‘arguably’ suppresses the respiratory drive,
potentially accelerating death.
SUSTAINABILITY
Sustainability
 The system or service can be maintained
at a steady state without exhausting the
resources available to support it

 Involves concepts such as long-term cost-

effectiveness, maintenance of quality,
equity of resource allocation and so on.
END

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