Health disparities Caring for vulnerable groups Personcentredness Reflection on your self Minor 2018 Prof. Dr. Maria van den Muijsenbergh, GP / streetdoctor

Causes of health disparities Air pollution Unhealthy work Poverty Loneliness Violence Social exclusion Chronic stress Low selfesteem Langdurig ongezonde omstandigheden Armoede – slechte huisvesting – geweld – fijnstof – onvoldoende groen Ongezonde leefstijl migratiestress Gebrek aan zinvolle dagbesteding Sociale uitsluiting – eenzaamheid - discriminatie -> laag gevoel zelfwaarde en self-efficacy + Tekortschietende gezondheidsvaardigheden -> chronische stress overstijgt vermogen lichaam zich aan te passen (allostasis)-> direct hormonaal effect: meer atherosclerose – meer DM Tekortschietende gezondheidsvaardigheden -> minder goed voor gezondheid zorgen -> ook daar ontevreden / onzeker over -> nog lager gevoel zelfwaarde Laaggeletterdheid – taalbarriere – stress – uitputting – ouderdom Fysieke beperkingen Kirkengen 2010 epidemiologisch bewijs schadelijke effecten chronische tegenslag (allostatic load) Commission on social determinants of health et al. Achieving health equity: from root causes to fair outcomes: Commission on Social Determinants of Health, Interim statement. 2007. Tomasdottir 2016 existentiele ongemak (gebrek zelfwaardering, , sociale contacten: draagt bij ana allostatic load en ziekte wel Marc Chagall loniless

Person centred care Example of the man with tennis elbow to illustrate the difference between protocol right care and person centred good care – need for broad bio – psycho-social approach Need for positive affirmative communication to restore the self

Good doctor sees and listens: need for personal continuity of care – being a person yourself Luke Fildes 1887 The doctor

Equity = everyone gets what he needs

Programme 3 months full-time 3d year medical school (age approx 21 years) 15 students Theme: health disparities and personcentred care for Migrants People with intellectual disabilities Homeless / prisoners Addiction / violence / psychiatry / low literacy Focus on the person and his experiences: Of the patient and of the student

Methods practice visits, patients in classroom, communication training, lectures, casus, Focus on storytelling and experiences Each week intervision meetings on personal experiences Start: telling our own life story and development Asignment: writing an essay on how they personnally view vulnerable people and their role as a doctor Last week : re-write the essay Pitch: “what has changed in yourself”

Observations Difficult / ackward in the beginning Used to protocols Used to “professional distance” Used to biomedical approach Recognition from own life experiences Impressive personal growth Pitches and presentations not traditional PPT’s Fairy tale Movie about the life of a homeless Refugee invited for role play consultation Animated movie

experiences students “Lost my fear for the homeless” “Got insight in my own vulnerability” “Lost my fear for the homeless” “Realise now that the emphasis on autonomy can be a symptom of creating a distance when you do not want to take responsibility as a doctor and person” “I was always trying hard to change myself, now I realise I can simply be myself – imperfection is human” “I feel the distance between me and the others is smaller, yet I know better how to set my own boundaries”

Lessons for next year More lectures / texts about psychology / self First introduction to philosophy Training debating skills