'Meeting People Where They're At': Experiences of Family Physicians Engaging Women Who Use Illicit Drugs

Abstract

PURPOSE There is little research exploring the experiences of family physicians caring for women who use illicit drugs. This study explores the experiences of these physicians in order to better understand the process of engaging these women in the patient-physician relationship. METHODSWe conducted a phenomenologic, qualitative study using individual, in-depth interviews with 10 family physicians working in inner-city Toronto and Ottawa, Ontario. An iterative and interpretive analysis was used.RESULTS Three broad themes emerged from the analysis. The predominant theme was that of the patient-physician relationship, which consisted of 2 phases: the engagement phase and the maintenance phase. During the engagement phase, issues such as access and women's experiences of trauma and violence were evident and impeded participants' ability to engage with this population. As such, the patient-physician relationship during the engagement phase was tenuous. Trust and presence were paramount during this phase. Once a family physician engaged a woman, the transition to the maintenance phase was made. Within the maintenance phase, 2 subthemes were identifi ed: continuity of care and "meeting people where they're at" (fi nding common ground). CONCLUSIONSThis study identifi ed a 2-phase process of the patient-physician relationship from the perspective of family physicians caring for women using illicit drugs: the engagement and maintenance phases. Our fi ndings identifi ed strategies to support the patient-physician relationship during each of these phases that have implications for improving the health of these women. Ann Fam Med 2011;9:244-249. doi:10.1370/afm.1225. INTRODUCTIONH aving a strong patient-physician relationship is good for one's health. Such a relationship may be especially important for marginalized women, such as those who use illicit drugs. Despite high use of emergency departments and walk-in clinics, 1-3 some studies have found marginalized women have low rates of outpatient visits and poor follow-up. [4][5][6] This pattern is contrary to that of women in the general population, who access the health care system more than men.7-9 Barriers these women face include spending time fi nding drugs, participation in sex work, homelessness, lack of health care coverage (eg, through loss of identifi cation), mental illness, lack of transportation, discrimination from health care clinicians, and distrust of the health care system. 4,[10][11][12][13][14][15][16][17] This lack of continuity is of particular concern given the high morbidity and mortality in this population. 11,15,17,[18][19][20][21][22][23] Just as a woman's health care needs are highest, her likelihood of accessing care is lowest.There is very little research studying the active role that family physicians can play in reducing the morbidity of women who use illicit drugs, particularly within the context of the patient-physician relationship. We speculate that higher rates of engagement in the patient-physician relationship will result in inc...

A conceptual review of engagement in healthcare and rehabilitation

“…Clinician interest was perceived to be demonstrated through behaviors such as sitting down with the patient to talk about their story, being present, respectful, attentive, going above and beyond, doing more than just the bare basics of the job [43,46,52] [37,52,55]. Both patients and providers suggested the connection was enhanced if the clinician was perceived to be engaged themselves [43] and passionate about their job [49].…”

“…Within the context of engagement, one paper suggested that the relationship between the provider and patient needed to be developed before commencing the "therapeutic sequence" [56]. The presence of the relationship appeared to create an atmosphere of collaboration and connection which then supported the patient to take action [42,44,46,50,53,56] and become engaged in the specific components of the therapy program or intervention [31,41,54] or simply to continue to attend the service [52].…”

“…Also identified as key to 'engaging with' were responsiveness to the patient [50], seeing them as a person rather than a diagnosis or impairment [30,43,45,46,48,49,52,53], demonstrating a genuine interest in getting to know the person and their story [50,53], addressing core needs [33,47], valuing their expertise [29,30,43,46] and strengths [31].…”

“…Within the context of engagement, one paper suggested that the relationship between the provider and patient needed to be developed before commencing the "therapeutic sequence" [56]. The presence of the relationship appeared to create an atmosphere of collaboration and connection which then supported the patient to take action [42,44,46,50,53,56] and become engaged in the specific components of the therapy program or intervention [31,41,54] or simply to continue to attend the service [52].Data from patients and clinicians suggested the process of engaging in healthcare started at, or before, the initial contact with the service and continued throughout the episode of care [48,49,57]. It did not appear to cease once the patient became involved with the service or in a therapy task; instead it was fluid and could further develop, or in fact diminish over time without on-going work and from both parties [10,30,43,44,48,58].…”

“…It did not appear to cease once the patient became involved with the service or in a therapy task; instead it was fluid and could further develop, or in fact diminish over time without on-going work and from both parties [10,30,43,44,48,58]. It was said to be maintained through an internal feedback loop, which involved the patient making on-going decisions to remain engaged [58] and through the clinician's way of working [52,57]; this could include periods of intermittent disengagement from services [43].With regard to published measures of engagement, the interaction and relationship between clinician and patient was considered within some measures, for example, the 'quality of the relationship' [32,34] 'attitudes toward staff ' [33], and the 'client's perception of being listened to' [40]. Of note is that items in the measures commonly focused on the patient's actions and perceived attitudes despite the body of evidence detailed above emphasizing the clinician's actions and perceived attitudes.…”