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Vital Signs

Training physicians to help patients take ownership of their care

For much of her 35-year career, Dr. Martha Regan-Smith has investigated ways to improve physician education. Now, paradoxically, that interest has her focusing on patient education. She will soon complete a Helmut Schumann Fellowship—designed for mid-career professionals seeking new approaches to problems—and begin training doctors how to teach their patients better self-management of chronic disease.

Care: "Most illness and most cost in the [health-care] system is chronic disease," says Regan-Smith, a rheumatologist and a professor of medicine at Dartmouth. Patients with diseases like arthritis and diabetes, which require careful monitoring of symptoms and adjustments in behavior, could assume more responsibility for their own care. And yet, Regan-Smith explains, many do not—either because they don't know how or because their doctors don't know how to encourage self-management.

Believing strongly that care should be designed both for and with patients, Regan-Smith applied for the two-year Schumann Fellowship with the goals of learning more about patient selfmanagement and finding or creating a curriculum to train doctors in using this technique.

Her quest took her from nearby Springfield, Mass., where she learned the basics of self-management; to Stanford, where she took a course with Dr. Kate Lorig, a pioneer in self-management for patients with arthritis; and ultimately to Flinders University in Adelaide, Australia, where all the pieces of the puzzle came together as she learned how physicians can promote selfmanagement using a method called the Flinders Model.

Developed by Dr. Malcolm Battersby, the Flinders Model is based on a structured way of interviewing patients. First, patients take a short self-assessment test to determine their current level of self-management skills. Next, a doctor or another health professional asks a series of questions to get at patients' understanding of their diseases and medications, as well as their involvement in monitoring symptoms and adjusting behaviors. Finally, patients are asked about the impact of the disease on their daily life. During the interview, Regan-Smith explains, the doctor's role is to listen and let the patient talk.

Goal: Then the doctor will ask, "What is your biggest problem in life and how do you feel about it?" Often the disease itself is the biggest problem and the patient's goal is to reduce its symptoms, but not always. Regan-Smith says patients of hers have identi-fied goals such as "I want to be able to renovate the bathroom in our house" or "I want to be able to put my children to bed at night." When they are working toward a realistic goal chosen by the patient, it is easier for the patient and the doctor to come up with a care plan together—and for the patient to stick with it.

One of Regan-Smith's patients, James Cote of Etna, N.H., was diagnosed with rheumatoid arthritis about 10 years ago. Now 56, Cote had to retire from his job with the phone company earlier than he'd have liked and to curtail activities he enjoyed, such as gardening and hunting.

Flare-up: "The thing about rheumatoid arthritis," Cote says, "is that you feel like you can still do things. But if I went out and hunted all day, I wouldn't be able to move the next day." Not surprisingly, the disease made him despondent, especially when he gave in to his urge to behave "normally" and then paid for it with a flare-up that brought days of pain and near-immobility. A little over a year ago, Regan-Smith invited Cote to accompany her to Springfield for the patient selfmanagement seminars. That changed everything, Cote says. Instead of fighting his disease and its treatment, he has learned to work within its limitations. Now, if he wants to go hunting, he goes out for a few hours. He might work in his garden for an hour at a time. "You can still do things," he says. "You just have to do them in moderation. If people could learn how to do this," he adds, "they could take better care of themselves and they wouldn't have to run to the doctor all the time."

While she was in Australia, Regan-Smith observed medical students being trained to use the Flinders Model; she hopes that American students will soon have the same opportunity. In fact, she says, she hopes that training in patient self-management will be mainstreamed into American medicine within the next five years.

Regan-Smith will be doing her part to bring that about. She was recently invited to present two workshops with Malcolm Battersby at the International Conference on Patient Self-Management, in British Columbia. "This is a big honor for me," she says, "with less than two years' work in self-management."

Catherine Tudish

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