The empowerment philosophy is based on the premise that human beings have the capacity to make choices and to be responsible for the consequences of their choices. Empowerment is defined as "an educational process designed to help patients develop the right level of attitudes, skills, knowledge (ASK) and degree of self-awareness necessary to effectively assume responsibility for their health-related decisions''.
Chronic disease care requires an educational approach substantially different from the traditional compliance-related approach (4). Self-management for diseases such as diabetes requires balancing many metabolic and lifestyle factors. Routinely, individuals with chronic diseases make many choices that affect their health for better or for worse (5). Being empowered thus means that patients have learned enough about their disease and the consequences of an effective management or the lack of it to enable them to judge the cost-benefit of adopting a wide variety of healthcare recommendations (4).
It would be hugely wrong to assume that medical practitioners letting go of some of their power, empowering patients and encouraging them to be partners would be more time-consuming. Conversely, it should lead to much faster shared understanding, greater patient satisfaction and improved health outcomes, as has been shown in the case of diabetes (6,7). However, it must be borne in mind and clearly understood that for patient empowerment to achieve the desired outcomes: 1. it must be born out of a systematic and sound process and 2. it must be developed and subsequently evolved as a way of thinking. Such processes must include provision of the appropriate information, training/education and take into account a change of culture in health systems influencing both healthcare professionals and consumers. These issues will be dealt with briefly below.
Information, Education and Training
Providing information to patients is a necessary condition for achieving the treatment aims for health and quality of life improvement (8). Also, information, if appropriate in format and delivery, could facilitate choice of treatment. Most governments hope that by encouraging individuals to take responsibility for their own health, they will empower patients to participate in decisions made about the management of their condition. There is no doubt that patients and their carers want and need more information about their health, their condition, treatment and outcomes, as well as information to support them in day-to-day living with long-term diseases (3,9-12).
There is variation among patients with regard to the amount and timing of information they desire. Although some may prefer to leave decisions to the health professionals, there is increasing evidence to suggest not only that patients want more information than they can get (9,13,14), but also that medical practitioners may overestimate the amount of information that they provide (13,14). Waitzkin (14) found that medical practitioners overestimated the time spent giving information by about a factor of nine. He also found that the characteristics of the patient influenced the amount of information presented to them, e.g. sex and social class. A communication gap extends from what patients want to know about their medicines to what they actually learn from their physicians and pharmacists—the patient heard me, but did he understand me? This failure of professional and ethical responsibility has serious implications for public health.
The uncertainties of patients who, for example, in the USA receive approximately 1.5 billion prescriptions a year contribute to the failure of many of them to benefit fully from their medications (11). Information about drug treatment is likely to influence compliance and therefore the efficacy of treatment: thus it is essential that patients have access to appropriate sources of accurate information (9). Let's look at some examples to illustrate the extent of the problem and reinforce the need for adopting a holistic approach.
For example, in the case of diabetes, usually 50% of patients are diagnosed, of whom 50% are compliant and consequently 25% of patients are effectively treated. In the case of asthma, less than 10% of patients use their medication technically as they should. In the case of hypertension, the compliance with medication is between 20 and 30%. Let's take this one step further: if we have a 95% chance of a patient being correctly diagnosed and a 95% chance of the patient receiving the right medication, but only a compliance rate of 50%, then shockingly, the maximum potential effect of the medication would be 95% x 95% x 50% = 45%. SOMETHING HAS TO BE DONE. To put this into perspective, in a climate of ever-increasing demand on our healthcare resources, what a waste of resources, time and energy not to mention the burden of all those complications arising from non-treated chronic diseases. The situation here is no different to where a customer in a butcher shop pays for a kilo of meat but is actually given only 0.45 kilo. This analogy holds true but with the fundamental difference that underselling of meat by the butcher does not cause any harm and untoward effect on the customer. Whereas, compromising the maximum potential effect of medication by 55% may cause the patient incalculable harm. Thus, as part of our professional and moral responsibility, we must ask ourselves "for how long can we go on spending scarce resources on reimbursing expensive, new innovative pharmaceuticals without providing patients with any guarantee of getting the maximum effect of their respective treatment?'' This could also wholly or partly be remedied by pharmacy practitioners adopting a holistic approach in their practice through the provision of pharmaceutical care (i.e. responsible provision of drug therapy for the purpose of achieving definite outcomes that improve the patient's quality of life) and pharmacist-led medicine management clinics.
Recent development in empowering patients in an effort to give them a voice and enable them to register their preferences when they are given the opportunity to choose from a number of alternative treatments has inherently brought about a change of culture. What this means is that patients as well as health professionals are experiencing something they have never done before. However, in some situations, one wonders whether patients and health professionals are ready to take on this two-way responsibility. For a patient who had never been given the opportunity to express his/her opinion about his treatments, suddenly he/she has been asked to make a difficult choice. Similarly, for professionals who, by and large, believed in paternalistic decision-making for centuries, this process places enormous pressure and naturally demands a change of culture. It has been reported that when patients have been given the choices, they have turned to the doctor and put the onus on him by responding "whatever you think doc"!
Simply, the answer is that both patients and health professionals must be appropriately trained and educated and prepared for such a change of culture. Frankly, it would be totally unfair to expect them to perform in the way described above and for patients to take on decision-making responsibilities without facilitating such a process. We first must teach them how to walk before we can expect them to run!
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