Saturday, 21 July 2007

Support

As a GP you can get support from colleagues both in the practice and outside. I was discussing patients who won't take advice with my helpful partner Martha, and told her about a patient I remembered who had required an operation urgently but told me she couldn't go along with the arrangements I wanted to make because of her work commitments. Martha told me that something similar had happened to her many years ago: she had been given medical advice which clashed with the plans she had already made for her life. Sensibly the consultant suggested that she take some time to think about things, and of course in a little while she realised that the consultant was right and took his advice.

In the case of emergency, perhaps a serious accident or a heart attack, the patient realises immediately that they have to put their normal life “on hold” for a while. But when the medical problem is less obviously urgent it can take time for patients to realise that they have to give their treatment some priority. We try to shoehorn so much into a brief consultation, and our thoughts race ahead thinking about likely outcomes and the best options. And of course we don't know all the details of our patients' lives. It's hardly surprising if the patient's thoughts are a little behind ours. Under such circumstances it is often helpful to arrange a second consultation a little later. We don't even have to say “go away and think about it before I see you again” because the patient will do that anyway. On reflection this is probably one of the reasons that diagnosis and management of puzzling cases become easier the second time I see the patient. Not only have I been thinking about the problem subconsciously, but the patient has almost certainly been doing some thinking about what was said and implied during the first consultation.

I got some good support from a hospital colleague yesterday when I saw a patient with a bad attack of erythema multiforme and really nasty mouth ulcers, but otherwise not looking too unwell and with no fever or systemic upset. I brushed up my knowledge of this condition and its more worrying counterpart the Stevens-Johnson syndrome (suggested by the mouth ulcers) using GP Notebook, but I wasn't sure about whether to prescribe steroids. I rang the dermatology Registrar on call who sounded very young and slightly worried, as though she had a bit of the imposter syndrome herself. But she gave me excellent advice (don't give steroids, Difflam mouthwash for pain relief, ring the out-of-hours service if things deteriorate over the weekend and ask them to call her) and has arranged a clinic appointment on Monday morning. She also took my patient's telephone number, and I think she is going to ring over the weekend to check that things have not got worse. Now that's what I call good service!

8 comments:

A. said...

I'm reminded of when an organisation I used to work for went through customer support training - as a whole. It was pointed out that that even the chief executive has a duty of support for the people who work for him, that the "customer" is not always what you might think. I rather wish my current CE had been though the same training...

The Shrink said...

A very helpful service from Secondary Care, helpful to both you and your patient . . . most excellent!

You know, if grateful, you could pop a letter in the post for their appraisal porfolio ;-)

cogidubnus said...

For some among us though, (and I do not include myself!), in a modern non-family oriented society, work has become the single most important factor in our lives - possibly the ONLY place we derive any satisfaction in life at all...interrupting it is unthinkable...

For others among us, things are more critical in a different sense...I recall twenty five years or more ago having chest pains, and being asked by a GP whether my work was particularly stressful...my response clearly was a cause of some concern as he advised me that the pain was in his view entirely stress-related and that I urgently needed to take three to four months off...

He seemed genuinely surprised when I replied that if I took his advice I'd certainly have no job, would probably lose my home and would, at the end of the process, have no way of supporting my family of wife and three kids...

Without seeking to knock either you or an excellent blog, (if for no other reason than I think you understand far more than most doctors!), I think some GPs need elementary lessons about day to day living uncushioneded by a (vast by most peoples measure) NHS salary

The Shrink said...

Cogidubnus, time off work for "stress" often isn't as helpful as intuitively might me thought. If "stressed" then taking time out from a stressful situation may at first glance seem a good idea and usually will help someone cope better (since the stress diminishes). But then they have to return to the stress, having experienced not coping and aversion to the stress, so overall what's changed? Nothing for the better, and arguably it's worse as they've learnt they're failing to cope and have to run away from it all.

Being adequately effective and sufficiently successful in the workplace when stressed is normalising, keeping real life in the really real world ticking along, so it desirable.

As a psychiatrist I have never given out a sick note or stopped anyone working unless they needed compulsory detention in hospital under the Mental Health Act (which amounts to fewer patients than I could count on one hand).

People need to learn to cope with "stress". If work is stressful, work needs to change or they need to cope better with the stress; time off isn't going to effect any sustained change.

Caveats apply . . . "stress" doesn't exist as a medical diagnosis or as a psychiatric formulation at all. Some disorders that you may think of as "stress" will need time out simply to stop an individual being overwhelmed. But invariably you're right, medics shouldn't be advising people to take time out of the workplace for "stress".

I would see sense in taking time out of a busy home or work life for planned intervention as sensible. It's pretty simple, really. Take 2 weeks out for procedure X or operation Y now and all's rosy, or wait 5 years when progression means you'll be performing suboptimally, need many more weeks before you're at the top of your game again, and technically it's harder (since the disorder has progressed).

In starkest terms, take 2 to 4 weeks out now to improve your health, or don't and die X years earlier than you should. Many common conditions (such as diabetes) will shorten life if not well managed but aren't immediately urgent. isn't it worth taking a little time out of busy lives to potentially buy more time in the future?

janeway said...

Some of the refusal to take medical advice, particularly if it involves something drastic like surgery, could be due to the 'if I don't think about it, it doesn't exist' syndrome. It's a lot easier to fall prey to that than most people realize - even the sharpest, most realistic of us are not immune.

And on The Shrink's last comment: after several years of intermittent but increasingly frequent symptoms, my doctor recommended that I have my gall bladder removed. As I was working full time and had a house full of youngish children, taking the time off for surgery and recuperation did not seem do-able. He said, 'You really don't want to be making this decision when you're in the ER, incapacitated with pain, and that's what's going to happen if you don't do this now.'
Good advice.

Dr Andrew Brown said...

Thanks to everyone for the interesting discussion. I find myself disagreeing a little with The Shrink (to my surprise). I think that people's resistance to stress can vary (one man's challenge is another man's despair, and often the same man at different times). A short period of "time out" can help someone to restore him or herself, particularly if there are problems at home as well as at work.

The Shrink said...

Disagreement's fine, there're lots of ways to skin a cat :-)

I agree with you that resistance to stress varies and I agree that "time out" can de-escalate intensity of being overwhelmed. I guess I'm in the happy position of being able to offer alternatives to taking substantial time out from work (some patients I have seen daily, for example) with a wide host of tools to play with such that interventions (sometimes including medication short term too) can give immediate relief to help manage problems whilst also helping effect change to assist in coping over the longer term.

But I concede, I'm not at the harsh end of Primary Care any more so proportionally have to help just a small number of such folk compared to your good self!

Dr Andrew Brown said...

The Shrink: It's always instructive to hear how the experts do things under (more) ideal conditions, and to think about how their insights can be applied in the rough & tumble of general practice.