Tag Archives: patient examination

Much of what’s wrong with healthcare is in the consulting room

It’s not that complicated. Not really. So where do you look for pathology? Inspection, palpation, percussion and auscultation. How does it look, how does it feel, how does it sound and what do you hear when you know where to listen closely. I’m talking about healthcare. Take a helicopter ride through your business.

Access

What is the route to your service? Where is the delay? How long do people wait in the waiting room? How do you know? What do you know about the people who use your service even before they are seated in your waiting room?

Greeting

What happens when people call or arrive in person? What message is conveyed?

Welcome we’ll do our best to help you today OR you are lucky we are ‘fitting you in’.

Just stand there- I’m dealing with someone on the phone.

We have no time- go complain to the manager/politician/ bureaucrat-consider yourself drafted to the cause.

Hold the line. We are dealing with something far more important but your call is really important to us so just listen to how good we are as conveyed by our prerecorded message.

Associated with that is what is perceived about your attitude that is not verbalised?

Look at ALL these posters and the many ways you can be helping yourself instead of wasting our time.

People vomit and pee while they wait so the seats have to be cleaned with detergent. Plastic is the best option.

If you want a drink go buy one at a cafe.

We rely on donations for our toys and magazines- we don’t have to provide anything OK? Now if you don’t like the stuff just watch Dr. Phil.

What do you mean you have been waiting a couple of hours? This isn’t McDonalds now take a ticket, sit down, shut up and wait. And turn off your phone so you can hear the old lady at the desk who has an embarrassing problem.

Communication

How long is the meeting with the provider? How does that meeting unfold? What is conveyed during the meeting?

Welcome- I’m so sorry you are not well. Tell me what happened? OR I haven’t got long what do you want exactly, spit it out be quick about it I need to get on with the next guy. Didn’t you see the queue out there?

I’m the important one around here- you are lucky I’ve chosen to be here today. Let me tell you about my holiday, my kids, my new car. It’s fascinating really!

Room 5. Quickly. Never mind my name.

Test/ Referral and Prescription

What action is taken at the consult and are you confident that is the best possible action?

I don’t have time for talk- have this test and take another day off to see me next week.

I don’t have time for you to take off your umpteen layers- go have a scan.

The rep told me this works- I only have to write a script.

If you want to get better take my medicine/advice/ referral or get lost.

What medicine do you want? How do you spell that? Tell me slowly I’m writing it down on your script.

Outcome

What proportion of people takes your advice/medicine/test? How many people stopped smoking? How many were triggered to lose weight? How many are addicted to prescribed medicines? How many were prescribed treatment or tests that were not indicated? Where’s your data? What are your plans for dealing with this?

Team

To what extent can you say that when people transition to another healthcare professional either on site or elsewhere that the relevant information follows them? Is everyone on the same page with the same patient?

All of this matters. All of it. Some of you can fix tomorrow. No need to wait for another round of healthcare reform. No one said it was easy. And whatever their business the best don’t compromise.  A lot of what can be fixed in healthcare takes place behind the closed doors of the consulting room.

Picture by Daniele Oberti

It is time to redesign the consulting room

Those who talk about the future of healthcare often describe the world as if the patient were a robot. They speak of devices and computers that will tell us what nature has already equipped us to know:

I haven’t slept well, I didn’t do much exercise today, I ate too much and I drank too much.

Many futurists appear to believe that providing information on a small screen will be enough to make all the difference to our behaviour. Doctors know this is a fantasy driven by commercial interests because they also know by virtue of their experience that so much of what we choose is contingent on more than just information. Some of these ‘innovations’ are losing market share faster than the receding snow cap of Kilimanjaro.

The overwhelming evidence is that if I decide to stop smoking it isn’t just because of the information that tobacco causes cancer. If  I commit to jogging four days a week it isn’t only because of information on how little I’ve moved today. These decisions are driven by much deeper psychological factors. We are ready to act on this ‘information’ only when the compulsion to make new commitments is greater than the urge to maintain the status quo. This happens in teachable moments. These are unique to each of us. When there is motivation and ability but we are also triggered to act then as BJ Fogg proposes we will do something different. Noting that we will sustain the effort only as long as it is a new habit. Therefore the task in the consultation is to gauge the motivation, enhance the ability, trigger the action and help to generate the habit.

The future of healthcare isn’t simply about access to information, whether on a wrist band or on a video screen. It isn’t only about access to the doctor or some pale imitation of the real thing.  The world of healthcare cannot exclude the physical presence of the practitioner as the one who can address all four aspects noted above by engaging people at the deepest human level. However as a starting point to designing the future we note that doctors are often at odds with the patient in the consultation:

There is evidence of a discrepancy between the numbers of problems noted by the patients and their doctors. It is possible that this is because doctors give priorities to certain diagnoses while ignoring others. Doctors may also focus on a known pre-existing condition of a particular patient rather than attending to the actual reason for the encounter. Thorsen et al

The authors further conclude:

The vast body of literature covering consultation patterns focuses on patients’ reasons for deciding to consult. Little research has focused on what patients have on their minds while in the waiting room regarding the forthcoming consultation.

Policy change that aims to turn back the clock so that people are forced to visit the same doctor who will do the same old thing….sound uninspired. If we consider the consultation as theatre then there are aspects that cannot be changed. Neither the actors nor the the plot (healthcare) can be changed. Patients will attend doctors who are trained to take a history, examine the patient and prescribe treatment. However the props and the script can be used to greater effect. These components impact on what the patient can see, smell, taste, hear and feel. The impact of these on the outcome of the consultation is the same as the impact on the person’s decision to buy anything.

whats-it-about

The economic reality is that people will be reticent to pay for something that is cheaper or readily available free elsewhere. However they are willing to pay for services that offer an experience. What is becoming a driver for innovation in primary care is the need to offer patients not only what they need but also what they want in terms of engagement with the practitioner. It is about changing how people feel in that space that we call an ‘office’ but could be redesigned as a ‘health pod’ in which the choreography aims to make it easier to identify teachable moments and trigger better outcomes.  An office is for bureaucrats, accountants and lawyers. We need to create a new environment that is conducive to selling health and healthy living.

If you are a doctor try this you might be surprised by the result:

seatHow else can you make the patient feel more valued in the encounter?

Picture by Jeff Warren

What can hairdressers teach their doctor?

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I had to try a new salon and it was an incredible experience. A long scalp massage, warm towels for my hands and an aroma-therapy treatment (3 sniffs of an oil??) made me feel ultra-pampered. I marveled at Elysa’s ability to tame my mane. The Power of a Haircut

Every shopping centre in Australia also now appears to have a massage parlour.

Stiff, painful muscles? Treatment: Myotherapy. Cost: From $100. Some companies cover myotherapy treatments under their insurance. My body+soul

Each year Australians spend over $4 billion on complementary and alternative medicine (CAM) and visit CAM practitioners almost as frequently as they do medical practitioners. But the spending doesn’t stop there:

The national survey of Australians (18-64 years)…. found over the past four weeks Australians spent an average of $594 each on clothes, accessories, beauty products and cosmetic services.Victoria, the self-proclaimed fashion capital of Australia, is home to the biggest spenders, who spend 19 per cent more than the national average at $707 a month. New South Wales spent $669 on average, 13 per cent more than average, followed by South Australia ($618) and Western Australia ($616). Suncorp bank

On the other hand a family doctor or GP might charge $50 for a standard consultation. The Medicare rebate for this is $36.30, leaving a gap of $13.70 for Australians to pay out of their own pocket. The average amount an Australian pays out-of-pocket for access to a GP is $29.56 a year (averaged across Australia).

So it seems that we are willing to pay up to $100 for one massage, $90 for one hair cut but pay a third of that sum for the services of a GP over a whole year. (Note: people pay far more for a ‘specialist’). The Value Tunnel explains this because the price is a function of the alternative options and the perceived value of that good or service. On that basis the cost of personal grooming is greater than a visit to a family doctor. It may be perceived that the alternative to visiting the doctor in your neighbourhood is to pick one who doesn’t charge above the Medicare rebate, visit a pharmacy or go to an emergency department. There are fewer viable alternatives to a haircut or massage from ‘that’ salon. There is constant downward pressure in the ‘Value Tunnel’ so that as the market accommodates more competition it drives the price down. That’s why a cup of coffee costs less than $5 and is unlikely to increase.

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What can GPs do to move up the Value Tunnel ? They must increase the perceived value while honing a niche market. While doctors no longer hold the monopoly on a range of things they also do things that others can’t offer. How can family doctors recast their brand in a way that sustains if not enhances the perceived value? Like every other business healthcare is subject to market forces. A recent survey offers businesses the following takeaways;

  • Know your customer and form a genuine relationship. What do the doctors know about their patients?
  • Make it easy for your customers to do business with you. To what extent are patients able to access what they need at the practice?
  • Solve your customer’s problems and go beyond what is expected. To what extent is the practice a one stop shop? What does the practice offer that other providers do not? ( Note: pharmacists and video consultations don’t include physical examination)
  • Look for opportunities to make an impression. Does the practice communicate well at every touchpoint?
  • Invest in your frontline staff; they are of course the face of your company, so it is essential that they happily reflect the core values you wish to promote. What are the reception staff like in the practice? Can patients be expected to be treated the same way by everyone they come across at the practice?

Picture by ndemi

Rehearse a plan for best care

It was a Saturday morning. Michael (43) popped in to get the results of his test as requested by the message left on his phone. He was told that the doctor who ordered the test wasn’t on duty that day so he asked to see whoever was available. That’s how I came to be involved.

From the records it wasn’t clear why the cortisol assay had been requested along with a battery of other tests all of which were normal. All the man could tell me is that he had asked for the test because:

It might explain a lot.

We had to start again. He was tired. He was stressed. He was working long hours at two jobs to pay a mortgage and service his debts. He had three young children and had been on antidepressants on and off for years. He wasn’t taking any tablets at the time. Didn’t smoke or drink. He was attending a counsellor.

There must be a reason I’m feeling so tired.

There was no obvious explanation for the borderline low result. Physical examination was entirely normal. No recent change in weight, normal blood pressure and no hint of major depression. No history of tuberculosis. No evidence of Addison’s disease.

I thought the ‘cortisol’ levels would be high I’m under a lot of stress.

We could now be on the way to more tests to determine what I suspected would be the final outcome that there would be no explanation. Life can cause people to feel this way with multiple physical symptoms including dysphoria, fatigue, insomnia, sexual dysfunction, weight changes and anxiety. Reasons may include poor choice of occupation, poor choice of partner, poor money management, poor time management, poor parenting. All of these can be associated with unfulfilling social interactions and or job dissatisfaction. Poor coping mechanisms then lead to physical sequela. People can be trapped in a spiral of increasing adverse consequences until lessons are learned and either alternative choices are forced upon them or circumstances conspire to offer the opportunity to start again.

People may not be ready to face their demons and that means they will ask to go searching for something more palatable than a need for a education,  honesty, economy or help.

As for doctors ordering tests could add to the complexity of the situation. Rare causes of fatigue are legion.  However typically people will ask if their fatigue is caused by some malfunction of their ‘hormones’ or if they are anaemic or diabetic.

In the case above there was no hint in the records what the patient had been told to expect after the test. His understanding of hormones was not recorded. He had read that cortisol is related to stress but not what the results might mean.

Because of the very low prevalence of pathology the Positive Predictive Value of ‘abnormal’ tests for middle aged patient without any positive history or examination findings is low for example:

Therefore the probability that one simple test will make the diagnosis is unlikely. People will need multiple tests and possibly a referral to a specialist once we embark on the hunt for the elusive physical cause. The likelihood of finding one when the patient doesn’t have any physical signs is vanishingly low. In sporting terms what’s needed is a set play. The question can be anticipated and the response to the initial request for tests needs to be crafted in advance. There is no better start then taking a full history and examining the patient before looking for the needle in the haystack.

Picture by Henti Smith

How can doctors remain the health practitioner of choice?

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You work as a checkout assistant at a supermarket. It’s Thursday. You’ve got a sore throat. It started a few days ago. You’re sneezing, you’re tired, you’ve got a headache. You’ve taken paracetamol already today it didn’t take away all the discomfort you still feel dreadful. You have several problems.

You want to feel better. Secretly you may be concerned that this is more than just a cold. You want to reassure the people that you are going to be well again in a few days. You want people to understand and accept that you are not functioning at your best at the moment. You want it all now not next week when you might be better or worse.

You may want information but you probably also want to have your discomfort validated and acknowledged. You’ve got some choices to make. You can try and get a doctor’s appointment. You can Google the symptoms and treatment. You can go to the local pharmacy or to your favourite alternative health practitioner. You can also try the emergency department. What you choose will depend on your previous experience of a similar episode but also on what your friends and or family suggest.

Upper respiratory tract infections are among the commonest reasons that patients seek the services of a general practitioner in Australia. It’s a presenting problem in one in twenty consultations. In the majority of cases these infections are viral and don’t require a prescription from a registered medical practitioner.

On the other hand there may be a financial cost to attending a doctor. You will need to take some or all of the day off and you may be required to queue despite you physical discomfort and it is more than likely that the doctor will tell you what everyone has already suggested that you will probably feel better in a few days. Whether you consider it useful to attend the doctor will depend on whether your needs were met last time. How do you feel at the end of the consultation? Did you feel that your visit was welcomed and that you were treated sympathetically? Did the doctor listen to you? Did they examine you? How did they convey the news that there isn’t any curative treatment available? How did they make you feel about the decision to make an appointment at the practice?

If we consider that such ‘trivial’ problems could be managed by another healthcare practitioner then we are asking for one in twenty encounters in practice to cease. How do we convey this message to our patients.

Colds are generally mild and shortlived, so there’s usually no need to see your GP if you think you have one. You should just rest at home and use painkillers and other remedies to relieve your symptoms until you’re feeling better. NHS Choices

The challenge is that most of what the patient is likely to present with as a new problem is similar: bronchiolitis, gastroenteritis, sprain/ strain, viral disease, contact dermatitis, back pain, bursitis, solar keratosis/ sunburn, tenosynovitis, tonsillitis, vaccination. These conditions or problems form a substantial chunk of the workload.

What can doctors add to these encounters that would make them a worthwhile experience for patients? Not just what might be ‘evidence based’ but also perceived as useful by the patient? Experiences that will retain the doctor and not a pharmacist, nurse, chiropractor, naturopath, homeopath, Dr. Google or ‘McDoctor-dial-a-doc’ as the healthcare practitioner of choice. In Australia doctors have typically 15 minutes. Here are some possible value adds:

  1. Offer advice on weight loss and exercise
  2. Advise on smoking cessation
  3. Review the patient’s medication
  4. Promote cancer screening
  5. Advise on vaccinations
  6. Examine the patient
  7. Document any possible risk factors for chronic illness
  8. All of the above

Back to the checkout assistant who is feeling dreadful, wants more than anything to go home after sitting in your waiting room, nursing a fever and a runny nose. It’s up to you of course but it I know which of the above I would want my doctor to do at that time. Patients tell it as they’ve experienced it and research has suggested what they are willing to pay for.

Picture by Tina Franklin

Clinicians can make a bad situation worse

He looked unremarkable.

I’m tired all the time. Otherwise I’m well he said smiling. No symptoms. Could eat more healthily I suppose. Don’t like alcohol and don’t smoke. Not losing weight. Can fall asleep on the couch at 11 in the morning. Not been anywhere abroad. Like going to the footy but don’t do much exercise.  Am not interested in sex. I want to rule out a physical cause.

His notes were scant. He’d consulted a few times over the years. Mostly self limiting conditions. A previous normal blood pressure was recorded. He wasn’t overweight. No psychiatric illness. No medications. We quickly went through every system recording a lack of any specific symptoms. Then paused.

Me: Are you married?

Him: Yes

More conversation about his children and his job as a retailer. His lack of exercise and his junk food diet.

Then we started talking about the elephant in the room.

Me: When did you start to lose interest in sex?

Him: It’s going on for a while. I’ve tried Viagra and that didn’t work. I’m moving out of the house tomorrow, we are trying a separation. We have been attending a counsellor and I just want to rule out a physical cause.

I was thinking.

So you don’t think that this might be contributing to your tiredness?

I bit my tongue. We went on to establish that he did not have ‘erectile’ dysfunction. From the history he had no difficulty achieving and maintaining an erection when he was on his own. His poor performance in the marital bed was not related to a physical cause. However the counsellor had sent him along just in case it might help the situation to be able to disclose that the relationship was suffering from some readily identified and treatable physical problem.

The consultation could have gone in another direction. I had a range of tests at my disposal that could have led us down any number of dead ends. We might even have discovered an incidentaloma to add to the confusion.

Sexual dysfunction is thought be to present in thirty five percent of male patients. It takes a bit of proactive questioning to get disclosure.

Despite this, sexual problems were recorded in only 2 per cent of the GP notes. Read et al

We were not going to solve the mystery on that occasion. I did a physical examination. It was normal. The hammers in my tool kit were put away, this wasn’t a nail. When it comes to sex, humans are complicated:

Research findings have implicated 5 factors that seem to differentiate sexually functional Ss from sexually dysfunctional Ss suffering from inhibited sexual excitement. These factors include differences in affect during sexual stimulation, differences in self-reports of sexual arousal and perception of control over arousal, distractibility during sexual stimulation, and differential sexual responding while anxious. David Barlow

I couldn’t establish what went on behind closed doors or in his mind at that time. We wouldn’t be talking about that but it was of critical importance to this man’s well being. This couple would get the help they deserved but it would take a recognition of the limitations rather than the expertise at my disposal that would assist them.

Picture by David Goehring

Cases too complex for a specialism other than general practice

It was a Friday evening. It’s almost always a Friday when this sort of case presents. She was in most ways unremarkable. She smiled readily, wasn’t evidently confused and worked in a senior administrative role. She came after work. This was the story:

I have a pain in my shoulder that becomes intense in my left arm pit. I can hardly bear to touch my arm pit. My hand becomes numb and cold. Today it’s so bad I’m finding it hard to turn the steering wheel.

I had 15 mins to sort this out, no scans, no blood tests, no discussion with a ‘team’ of young doctors working to pass their exams. She was describing symptoms that may have indicated a neurological emergency. And yet none of it made sense. She hadn’t fallen or been involved in any other trauma. There was no rash, no swelling. She swung her left arm over her head without any difficulty. I could not detect neurological signs, reflexes were normal. No Horner’s syndrome. No breast lesion. No obvious sensory loss. Twenty minutes later I could find nothing in her records or in her presentation that gave me any clue to the cause of these symptoms. And yet she was clearly worried. Regardless of the outcome I had to achieve one thing- this person like every other person who seeks help from a general practitioner needed to know that she had been taken seriously. Not for us the option of sending her back to whence she came with a note:

No organic pathology. Refer elsewhere.

A number of possibilities came to mind. Top of the list was ‘brachial plexus neuropathy‘ or Thoracic Outlet Syndrome. There were no objective signs at the time of presentation and I had never seen this before albeit that I had read about it sometime while at medical school. But then that’s primary care. We are the first port of call for anyone entering the healthcare system and often they present too early for anything to have manifested objectively. Not for us the text book presentation. About this diagnosis we know that:

Damage to the brachial plexus usually results from direct injury. Other common causes of damage to the brachial plexus include:

  • Birth trauma.
  • Injury from stretching.
  • Pressure from tumours.
  • Damage from radiation therapy.

Brachial plexus neuropathy may also be associated with:

  • Birth defects.
  • Exposure to toxins.
  • Inflammatory conditions.
  • Immune system issues.

There are also numerous cases in which no direct cause can be identified.

We also know that:

Signs and symptoms of thoracic outlet syndrome vary from patient to patient due to the location of nerve and/or vessel involvement. Symptoms range from mild pain and sensory changes to limb threatening complications in severe cases. Physiopedia

Diagnosis is difficult, tests and examination can be normalprognosis is variable. By the time a diagnosis was made weeks later and she presented to a specialist everything was obvious. But on that Friday evening with a surgery full of patients I was on my own. My patient trusted that I would not let her walk out of there only to lose a limb. Assuming a benign cause she would be back and need more. This was the start of a longterm relationship and how I managed this episode would set the tone for the duration.

While improvement may begin in one to two months, complete functional recovery may not be achieved for up to three years or longer in some cases. Tsairis et al

Picture by Mahree Modesto

Why general practitioners are crucial to the economy

The odds of experiencing an event that will descend you briefly into your own private hell are significant.

These odds are much greater than the odds of getting something that requires heroic intervention:

Good news = You are more likely to catch a cold, sprain an ankle or have a runny nose than suffer anything more serious.

Bad news = What happens if you get one of the aforementioned ‘minor illnesses’.  I am living with fractured ribs this week. This is what happens:

  • You are told there is no treatment and no definite recovery period.
  • You can’t tie your own shoe laces, take off your socks or dry your back after a shower.
  • You can’t push open doors.
  • You can’t get out of, our turn over, in bed.
  • You dare not sneeze or pick anything off the ground.
  • You get persistent headaches because of paravertebral muscle strain.

The pain will get worse before it gets better. So at first you might go to the emergency department (ED) because your family will insist. At the ED you will be X-rayed. You will be prescribed analgesia and advised to take time off.  A day or two later in increasing pain you will toy with the idea of going back to hospital just in case they’ve missed something.  The codeine will cause constipation making things worse. Some doctors will advise you to take tramol others will advise against it. A specialist might recommend intercostal nerve blocks (anything looks like a nail when you are armed with a hammer). The cost of getting medical attention will mount. What you will need the most is symptom relief and a greater sense of control. Your only hope is a good GP.

In desperation you might consult YouTube for any useful hints on how to recover. This person has clearly never experienced rib fractures. I hope no medical student thinks this is how to approach the examination of anyone with this condition. On the other hand this person clearly has.

Health economists tell us that the increased costs in the healthcare system are due to unnecessary tests and treatments.

On average, a 50-year-old now is seeing doctors more often, having more tests and operations, and taking more prescription drugs, than a 50-year-old did ten years ago

You are at greater risk of ‘minor illness’ than any other illness. Yet we know that is when we are likely to request tests and treatments in the vain hope it will hasten the recovery. Good GPs  reduce this morbidity as well as the cost of caring for people when time is the only treatment.

This week we launched the Journal of Health Design. The scope of our journal is to support researchers who are developing innovations inspired by the patient experience of healthcare. This was also the week that the Royal Australian College of General Practitioners supported our team to conduct research that aims at supporting GPs in consultations with people with viral infections when antibiotics are not indicated.

Picture by Matt Pelletier

Are we allowing technology to hamper healing?

13866052723_2020820f89_zYou’ve heard it before

I’m at that age doctor when I should have a full body scan. Like it’s being offered here.

or at the very least

Can I have a scan doctor?

When offered radiological tests immediately the public is led to believe that such investigations are necessary. In Australia between 1996 and 2010, total CT scan numbers have increased almost 3 fold. (Medicare Australia, Group Statistics Reports 2010, Report No. 2. Available from here). The number of CT scans is reportedly growing at about 9% each year in Australia. In the USA there are estimated to be 62 million scans per year as compared with about 3 million in 1980 with growing concern about the wisdom of exposing people to increasing levels of radiation.

At the same time the value of most tests carried out is also in doubt. In a study of an academic medical department it was concluded that:

…almost 68% of the laboratory tests commonly ordered…. could have been avoided, without any adverse effect on patient management; this figure corresponds to 2.01 unnecessary tests ordered/patient during each day of their hospitalisation. Miyakis et al

In the context of hospital medicine inappropriate test ordering adds to the cost of healthcare. In primary care there is the additional concern that tests fail to achieve any useful outcome. The patient may experience considerable dissatisfaction with the failure of diagnostic tests to explain their pain and may feel they they are being labelled a malingerer.

Therefore one might pause to reflect before requesting yet another investigation. Physical examination, which arguably obviates the need for many tests has an enormous value to the patient even in the context of advanced cancer.

Most patients (83%) indicated that the overall experience of being examined was highly positive (median score, 4; interquartile range [IQR], 2-5; P ≤ .0001). Patients valued both the pragmatic aspects (median score, 5; IQR, 4-5) and symbolic aspects (median score, 4; IQR, 4-5) of the physical examination. Increasing age was independently associated with a more positive perception of the physical examination (odds ratio, 1.07 per year; 95% confidence interval, 1.02-1.12 per year; P = .01). Kadakia et al

According to Paul Little and colleagues reporting in the BMJ perceived pressure from patients is a strong independent predictor of whether doctors examine, prescribe, refer, or investigate in primary care. It seems, at least in part that we may be responding to such pressures to order necessary tests. On the other hand our perception of the value of examination may be blunted.  As Professor Little wrote:

The doctors thought, however, there was no or only slight medical need among a significant proportion of those examined (89/580, 15%), given a prescription (74/394, 19%), or referred (27/125, 22%) and among almost half of those investigated (99/216, 46%).

One could argue with the doctors’ impressions of the ‘need’ for medical examination. To some extent it is necessary in every case. We may be losing the sight of the therapeutic effect of the examination as part of effective communication in primary care. There is a need to revitalise our ability to heal. At a time of increasing costs in healthcare examining patients is a relatively low cost intervention with significant potential to improve outcomes.

Picture by COM SALUD

Address the patient’s greatest fears ASAP

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I think my son has meningitis.

I glanced at the boy who was now walking across the room to look more closely at a poster on antenatal care.

I don’t think so was my first thought, followed by thank you for telling me exactly what you are worried about. It’s not always that easy. Often the ‘hidden agenda’ remains just that- hidden. The longer it remains unchallenged the greater its hold. Then it’s much less easily to address head on. Sometimes you get a sense of it from the smell of fear as it comes into the room. Occasionally it’s hidden in a request for curious tests:

Could you check my vitamin levels?

My favorite is those who come for ‘check ups’ and are seemingly asymptomatic. I recommend the paper by Sabina Hunziker and colleagues. They studied 66 cases of people who explicitly requested a ‘check up’. All consults were video recorded and analysed for information about spontaneously mentioned symptoms and reasons for the clinic consultation (“open agendas”) and for clues to hidden patient agendas using the Roter interaction analysis system (RIAS).In RIAS, a cue denotes an element in patient-provider communications that is not explicitly expressed verbally. It includes vague indications of emotions such as anxiety or embarrassment that patients might find difficult to express openly and that prevent the patient from being completely forthcoming about his or her reasons for requesting a consultation. All 66 patients initially declared to be asymptomatic but this was ultimately the case in only 7 out of 66 patients.

Back to the boy with ‘meningitis’. He had a fever and aches and pains. However according to Dr. Google, who mum consulted just before rushing to the surgery, if the child had ‘cold hands’ one of the possibilities is that the child has meningitis.

I examined the child thoroughly and found that he had a mild pyrexia and signs of an upper respiratory tract infection. He was awake, alert and clearly interested in his surroundings. He was persuaded to smile and had no signs of septicemia. As this is a common fear in anxious parents I am prepared with standard advice that might be helpful and outline the way meningitis presents. Something I have encountered in practice.

There are many other fears that are presented in an urgent consult. In 99.99% of cases, they are unfounded. However the opportunity to allay the patient’s fears is also an opportunity to forge a bond that may be of enormous assistance when those fears prove to be well-founded. It may be worth considering how you will respond to patient fears of the many monsters that appear in the dead of night; cancer, heart attack, Kawasaki’s disease and meningitis in particular. Bearing in mind these monsters do occasionally present in the most atypical fashion.

Picture by Pimthida