Introduction to the Clinical Process
Patients consult clinicians to obtain relief from symptoms and to return to full health. When cure is not possible, intervention to improve the quality of life is warranted. Consequently, oral healthcare providers’ primary obligation is the timely delivery of quality care within the bounds of the clinical circumstances presented by patients. The provision of quality care will depend on timely execution of the clinical process.
The clinical process represents a continuous interplay between science and art and may be conveniently divided into three phases.
Phase I of the clinical process is physical evaluation and consists of eliciting a historical profile, performing an examination, obtaining appropriate radiographs, ordering laboratory tests, and, when indicated, initiating consultations with or referrals to other healthcare providers. The information obtained is systematically recorded. In order to optimize the yield, clinicians need to possess an inquiring mind, discipline, sensitivity, perseverance, and patience.
Phase II of the clinical process involves an analysis of all data obtained during Phase I. Interpretation and correlation of these data, in the light of principles gained from the basic biomedical and clinical sciences, will create the diagnostic fabric that will lead to a coherent, defendable, relevant, and timely diagnosis. This is an intellectual and, at times, intuitive activity. In making diagnoses, clinicians must recall their knowledge of disease.
Phase III of the clinical process is centered around the timely development and implementation of necessary preventive and therapeutic strategies and communicating these strategies to the patient or guardian in order to obtain consent and to encourage compliance with and participation in the execution of the plan. In deciding on management strategies, clinicians must think in terms of illness and the total impact of a disease on a given patient and his or her immediate family.
A four-part control cycle (plan-do-check-act) introduced to industry in the 1930s is applicable to total quality management (TQM) in the clinical process and is reflected in the acronym CEAR (pronounced CARE): criteria-execution-assessment-response. Criteria are intended to maintain established standards. Ideally, standards should be based on knowledge derived from well-conducted trials or extensive, controlled observations. In the absence of such data, they should reflect the best-informed, most authoritative opinion available. Execution is the implementation of activities intended to meet stated standards. Assessment is comparing the impact of execution (outcome) against the stated standards. Response refers to the activities intended to reconcile differences between stated standards and observed outcome (Table 1.1).
TQM provides the fabric for a disciplined approach to work design, work practices, and constant reassessment of the clinical process. In TQM there is no minimum standard of “good enough”; there is only “better and better.” Defects are signals that point to parts of a process that must be improved so that quality is the result.
|Reconsider the criteria (standard).|
|Redesign the activities intended to achieve the criteria|
|Review the assessment process.|
|Remediate without changing the criteria or the activities intended to achieve the criteria.|
|Reject the samples that do not meet the criteria.|
|Apply residual learning to the next control cycle.|
The amenities of care represent the desirable attributes of the setting within which the clinical process is implemented. They include convenience (access, availability of service), comfort, safety, and privacy. In private practice these are the responsibilities of the clinician. In institutional settings, the responsibility lies with the administrators of the institution.
The clinical process is a combination of intellectual and manipulative activities by which disease is identified and illness is treated. As we seek to define its quality, we must consider the performance of clinicians. There are two elements in the performance of clinicians that affect quality, one technical and the other interpersonal.
Technical performance depends on the knowledge and judgment used in arriving at appropriate diagnostic, therapeutic, and preventive strategies and on the skillful execution of those strategies. The quality of technical performance is judged in comparison with the best in practice. The best in practice, in turn, has earned that distinction because it is known or is believed to lead to the best outcome. The second element in the performance of the clinician that affects quality is interpersonal skills (see “Patient-Doctor Communication in the Clinical Process”).
In considering variables that affect the quality of the clinical process, contributions made by the patient, as well as by family members, must also be factored into the equation. In those situations in which the outcome of the clinical process is found to be inferior because of lack of optimal participation by the patient, the practitioner must be judged blameless.
Effective control over quality can best be achieved by designing and executing a clinical process that meets professional standards and also acknowledges patients’ expectations. The information from which inferences can be drawn about quality may be classified under three headings: structure, process, and outcome.
In addition to the amenities of care discussed earlier, structure also denotes the attributes of material resources (e.g., facilities and equipment), human resources (e.g., the number and qualification of personnel), and organizational resources (e.g., convenience [access, availability of service], comfort, safety, privacy, methods of payment). Since structure affects the amenities of the oral healthcare setting, it can be inferred that good structure increases the likelihood of a good process.
Process denotes what is actually done in the clinical process. It includes the clinician’s activities in developing and recommending diagnostic, therapeutic, and preventive strategies; and the execution of those strategies, both by the clinician and the patient. Process also includes the values and virtues that the interpersonal patient-doctor relationship is expected to have (i.e., confidentiality, informed consent, empathy, congruence, honesty, tact, and sensitivity). In general, it can be assumed that a good process increases the likelihood of good outcome.
Outcome denotes the effects of the clinical process on the identification and treatment of consequential problems, improvement in health, and changes in behavior. Because many factors influence outcome, it is not possible to determine the extent to which an observed outcome is attributable to an antecedent structure or process. However, outcome assessment does provide a mechanism to monitor performance to determine whether it continues to remain within acceptable bounds.
Poor skills in communicating with patients are associated with lower levels of patient satisfaction, higher rates of complaints, an increased risk of malpractice claims, and poorer health outcomes. Clearly, in the clinical process, the performance of clinicians as it relates to interpersonal skills is the very source of their vulnerability. The process of establishing a patient-doctor relationship, however, is not easy. To illustrate this point, let us consider the clinical process in dealing with a patient in pain, the most common complaint causing a person to seek the services of an oral healthcare provider.
Ideally, the clinician should initiate the clinical process in a quiet, comfortable, private setting and foster a warm, friendly, concerned, and supportive approach with the patient. However, this may be a challenging task since it is well established that many patients experience anticipatory stress in the oral healthcare setting. Such stress may provoke patients to experience a state of disequilibrium or crisis characterized by anxiety, that is, an intense unpleasant subjective feeling and an inability to function normally. The sequence of events, which leads from equilibrium to a crisis situation (disequilibrium) and back to equilibrium, includes a hazardous event, a vulnerable state, a precipitating factor, an active crisis state, and a reintegration state.
A hazardous event is any stressful life event that taxes the patient’s ability to cope. The experience can be either internal (the psychological stress of dental phobia) or external (such as a natural disaster, the death of a loved one, or the loss of employment). Clinicians may be unaware of such hazardous events and patients may not readily volunteer such information.
Depending on subjective interpretation, one person may see the hazardous event as a challenge, while another may see the same event as a threat. If one views the event as a threat, the increased physical and emotional tension may manifest itself as perceptions of helplessness, anxiety, anger, and depression.
The precipitating factor (in our example, pain) is the actual event that moves the patient from the vulnerable state to the active crisis state. This event, especially when added onto other stressful life events (hazardous events), can cause a person to suffer a crisis. In susceptible patients, not only pain but even minor dental problems requiring a visit to the dentist can precipitate an active crisis state.
During the active crisis state, the patient is emotionally and psychologically aroused because of pain, negative self-critical thoughts about what brought him or her into the clinician’s domain, unfamiliarity with the environment, and fear that the clinician will be judgmental or punitive. The model for crisis intervention has six characteristic phases and follows the acronym CRISIS: calm confidence, responsiveness, involvement, supportiveness, “I can” statements, and situation.
People who are in a crisis situation generally are not attuned to the words being spoken to them, but they are responsive to nonverbal communication. Behaviorally, calm confidence is displayed by establishing eye contact with the patient, by guiding the patient into the chair, or by touching the patient’s shoulders. All of these measures reflect inner self-confidence and control over the situation. If the clinician is perceived as being calm and confident, the patient is more likely to calm down and give trust and control to the clinician.
Responsiveness is conveyed through verbal communication. It requires a willingness to be directive and to give firm guidance while responding to both the emotional and oral healthcare needs of the patient. The clinician with empathy for the patient does not convey a negative value judgment and, therefore, builds rapport with the patient.
A patient in crisis will exhibit behaviors suggesting helplessness or dependency, which might make the clinician feel all the more responsible. Clinicians must relinquish this sense of total respons/>