IL CENTENARIO della Clinica Pinna Pintor di Torino La centralità del paziente nella scelta delle cure

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1 IL CENTENARIO della Clinica Pinna Pintor di Torino La centralità del paziente nella scelta delle cure ANTONIO MATURO Università di Bologna Symposium: Patient Centered Care. PERCEIVED QUALITY OF CARE Arturo Pinna Pintor Foundation - Torino (Italy) Saturday September 25, 2004

2 Beyond the traditional questionnaire: from patient satisfaction to analysis of care experience

3 Italian Quality Paradox (Trabucchi) People show a very low trust on health care organizations, while satisfaction for care services received inside the hospital are very high. Why?

4 Are surveys on patient satisfaction reliable? Are patients suffering of a weakness that produces bias? (related to the situation of the interview) Should researches ask for experiences and facts instead of levels of satisfaction and/or perception? (Picker)

5 Seven levels of trust Generalized trust, that is trust in social order itself or trust in a particular form of social order: America is a great society! ; Segmental trust, that is trust in institutional segments of society like economy, education, justice: Dutch health care system is highly developed! ; Technological trust, that is trust in technical systems like financial markets, transport systems, telecommunications;

6 Organizational trust; that is trust in organizations like universities, corporations or a peculiar hospital; Commercial trust, that is trust in goods that are an answer to human needs. This kind of trust can have a high degree of generalization Japanese cars are very safe! or a low one: A book written by Umberto Eco must be very exciting! ;

7 Positional trust, that is trust given to peculiar social roles: judges, doctors, priests, etc.; Personal trust, that is trust given to someone we consider special : a friend, a teacher etc. Trust given to relatives can be called private trust.

8 In stead of speaking of a paradox we can, in a very simple way, distinguish between segmental trust and personal trust. See: Giddens [1990]; Sztomka [1995]

9 People saw health care institutions like Kafka s castel: something very grimy and disturbing, but when someone had interpersonal relationships with health professionals the effects were positive. The human value produces trust. People with low expectations express high satisfaction for decent care and increase their trust in health care services

10 What can we learn form this paradox? 1. We need reliable tools in order to evaluate patient satisfaction; 2. There are many concepts that are often inestricably interwoven: trust; satisfaction; perception; experience; Erlebnis We need theoretical reflections in order to develop more consistent hyphotesis

11 Narrative-Based Medicine Patient situation: weakness and need of help; technical incompetence; emotional involvement [Parsons 1965] A difficult situation in which the information can be distorted Narrative-Based Medicine tries to reduce the bias connected to quantitative studies conducted in situations of illness and disability substituting the search of objectivity with the interpretation of subjectivity.

12 Narrative-Based Medicine Narrative is a form in which experience is represented and recounted, in which events are presented as having meaningful and coherent order, and in which activities and experiences associated with events are described along with the significance that lends them their sense for the persons involved [Good & Good 2000: 381]

13 Studies in illness narratives can re-orient research in patient satisfaction a more reliable correspondance between experience (erlebnis) of illness and evaluation of care

14 Disease,Illness, Sickness: a complex triad Disease: physiological alterationas represented in medicine illness: subjective perception of feeling ill Sickness: social representation of illness

15 Disease,Illness, Sickness: a complex triad The typical case is: A person feels ill; the doctor certifies his state (disease) society labels him as a sick person

16 Disease,Illness, Sickness: a complex triad disease sickness illness disease sickness illness 2 3 5

17 Disease,Illness, Sickness: a complex triad 1. Disease and sickness without illness: high values in blood analysis 2. Disease and illness without sickness: alcholism 3. illness and sickness without disease: certain kinds of headache

18 Disease,Illness, Sickness: a complex triad 4. Disease without illness and without sickness: physiological alteration that are not perceived by the person nor gives the right of a changement in the social status; 5. illness without disease and without sickness: melancholy; ansiety 6. Sickness without disease and without illness: omosexuality (in some society); masturbation

19 Disease,Illness, Sickness: a complex triad Such dimensions of illness (or sickness or disease?) can be fruitful connected with Narrative-Based Medicine. Narrative-Based Medicine can be seen has the first step for the construction of quantitative research in patient satisfaction Narrative-Based Medicine is also an autonoumos method of reseach

20 References Cipolla C., Giarelli G. (a cura di) (2002), Dopo l aziendalizzazione. Nuove strategie di governance in sanità, Salute e Società, vol.i, n.1. Cipolla C., Giarelli G. Stzomka e Altieri P L. (a cura di) (2002), Valutare la qualità in sanità. Approcci, metodologie e strumenti, Angeli, Milano. Cipolla C. e Cinotti R. (a cura di) (2003), La qualità condivisa fra servizi sanitari e cittadini, Angeli, Milano

21 References Giddens A. (1990), The Consequences of Modernity, Cambridge University Press, Cambridge. Good, B.J e Del Vecchio-Good, M.J. (2000), Parallel Systers : Medical Anthropology and Medical Sociology, in Bird C.E., Conrad P. Fremont A.M. (Eds.) (2000), Handbook of Medical Sociology, Prentice Hall, New Jersey Stzomka P. (1996), La fiducia nelle società comuniste, Rubbettino, Soveria.

BIOGRAPHY (Date of Birth: 12/09/1972).

Curriculum vitae Prof. Massimo Miglioretti Associate Professor Department of Psychology University of Milan-Bicocca (ITALY) e-mail: massimo.miglioretti@unimib.it BIOGRAPHY (Date of Birth: 12/09/1972).