Tag Archives: Symptoms

For best results engage the entire decision making apparatus

I’ve been sick for two days. I have a runny nose, headache, cough and I’m tired.

We agreed that it was very unpleasant having these symptoms when you are moving boxes around a warehouse all day. I examined him and found signs of an upper respiratory tract infection but nothing worse. Now comes the crucial part. If you are a doctor what do you say in the circumstances? You must have your speech ready because you will almost certainly consult someone like this every day, probably more than once a day. In an essay published in the BMJ Trisha Greenhalgh and colleagues wrote:

Evidence users include clinicians and patients of varying statistical literacy, many of whom have limited time or inclination for the small print. Different approaches such as brief, plain language summaries for the non-expert (as offered by NICE), visualisations, infographics, option grids, and other decision aids should be routinely offered and widely used. Yet currently, only a fraction of the available evidence is presented in usable form, and few clinicians are aware that such usable shared decision aids exist. BMJ 2014

What she appears to be hinting at is that words are not enough and may not efficiently convey what this man needs to make a decision for himself. He has already decided for whatever reason that he needs to see a doctor. He was probably able to ‘self-care’ by taking ‘over the counter’ symptomatic measures. Setting aside the notion that he might have presented to get a medical certificate to claim time off what else may be on his agenda? If we postulate that he might want prescribed medicines believing that they will hasten this recovery then there is the prospect of a disagreement with you as the ‘evidence’ suggests otherwise. He probably has a viral illness. But as David Spiegelhalter and colleagues wrote in Science:

Probabilities can be described fluidly with words, using language that appeals to people’s intuition and emotions. But the attractive ambiguity of language becomes a failing when we wish to convey precise information, because words such as “doubtful,” “probable,” and “likely” are inconsistently interpreted. Science 2011

What the person with the cold needs to know is that we cannot be sure what precise ‘bug’ has caused his symptoms. That the most likely cause is a virus but that his symptoms now do not predict the duration or severity of his illness. However most people get better within 10 days and he is probably suffering the most he will through this illness today. The worst symptoms are those he now describes. the cough may linger for a couple weeks.  Symptomatic treatment might help him feel better and that people who have been prescribed antibiotics do not get better any faster (that last bit is my team’s research which hasn’t yet seen the light of day in a peer-reviewed journal). However he may not factor all of this information into his thinking without pictures. We need to consider how he makes the decision to take your advice. Scientists have studied this and come up with some helpful advice recently. For a start the patient is unlikely to make a decision based on logic alone.

Behavioral economic studies involving limited numbers of choices have provided key insights into neural decision-making mechanisms. By contrast, animals’ foraging choices arise in the context of sequences of encounters with prey or food. On each encounter, the animal chooses whether to engage or, if the environment is sufficiently rich, to search elsewhere. Kolling et al

There are three treatment options; prescribe an antibiotic now, defer prescribing for a couple days or prescribe nothing. The latter is the appropriate course however a goal in this situation is to reach consensus with this person. To present the data to him in a way that engages his entire decision making apparatus. You are able to usher him out the door without anything only to find that he has lost faith in you. How he feels about the matter is critical:

A few years ago, neuroscientist Antonio Damasio made a groundbreaking discovery. He studied people with damage in the part of the brain where emotions are generated. He found that they seemed normal, except that they were not able to feel emotions. But they all had something peculiar in common: they couldn’t make decisions. The big think

The more challenging approach is to communicate respectfully, appropriately and effectively. Pictures can now assist as never before. Yet the habit of using pictures is neither taught nor practised consistently in clinics. Spiegelhalter again:

   The most suitable choice of visualization to illustrate uncertainty depends closely on the objectives of the presenter, the context of the communication, and the audience. Visschers et al. concluded that the “task at hand may determine which graph is most appropriate to present probability information” and it is “not possible to formulate recommendations about graph types and layouts.” Nonetheless, if we aim to encourage understanding rather than to just persuade, certain broad conclusions can be drawn, which hold regardless of the audience.

His team’s recommendations:

  • Use multiple formats, because no single representation suits all members of an audience.
    Illuminate graphics with words and numbers.
  • Design graphics to allow part-to-whole comparisons, and choose an appropriate scale, possibly with magnification for small probabilities.
  • To avoid framing bias, provide percentages or frequencies both with and without the outcome, using frequencies with a clearly defined denominator of constant size.
  • Helpful narrative labels are important. Compare magnitudes through tick marks, and clearly label comparators and differences.
  • Use narratives, images, and metaphors that are sufficiently vivid to gain and retain attention, but which do not arouse undue emotion. It is important to be aware of affective responses.
  • Assume low numeracy of a general public audience and adopt a less-is-more approach by reducing the need for inferences, making clear and explicit comparisons, and providing optional additional detail.
    Interactivity and animations provide opportunities for adapting graphics to user needs and capabilities.
  • Acknowledge the limitations of the information conveyed in its quality and relevance. The visualization may communicate only a restricted part of a whole picture.
  • Avoid chart junk, such as three-dimensional bar charts, and obvious manipulation through misleading use of area to represent magnitude.
  • Most important, assess the needs of the audience, experiment, and test and iterate toward a final design.

The last offers a call to arms for innovators.

Picture by Alan

More can be done to help people who consult doctors

In general practice patients generally present with undifferentiated conditions. People come for help with a cough and not ‘pneumonia’, back pain and not ‘metastatic prostatic cancer’, fatigue and ‘not diabetes’. In a study published in 2015 it was reported that a diagnosis is not established in 36% of patients with health problems. According to the research team half of the symptoms were expected to resolve or persist as ‘medically unexplained’. In their summary the team concludes that:

The study highlights the need for a professional and scientific approach to symptoms as a phenomenon in its own right. Rosendal et al

We also know that the commonest symptoms relate to the musculoskeletal system, respiratory system and the digestive tract. As long ago as 1984 Gordon Waddell and colleagues made a similar point in the BMJ :

The amount of treatment received by 380 patients with backache was found to have been influenced more by their distress and illness behaviour than by the actual physical disease. Patients showing a large amount of inappropriate illness behaviour had received significantly more treatment (p <0 001).

They concluded:

We know that a standard medical history and examination provide a wealth of information not only about the disease from which the patient is suffering but also about how that particular person is reacting to and coping with his or her illness. What is necessary now is to devote as much time and effort to the study and understanding of illness behaviour as we do at present to the investigation of physical disease. Only thus can we put the art of medicine on to a sound scientific basis.

Decades later these words are prophetic and we find that the thrust of research is on the diagnosis and treatment of specific pathology rather than on how to help people to cope with persistent back pain, acute cough or ill defined abdominal pain. This continues to be a bone of contention between doctors and patients as was illustrated in a classic paper by Joe Kai writing about the management of illness in preschool children in general practice:

Parents expressed a need for more information about children’s illness. Advice about the management of common symptoms was insufficient. They sought explanation and detail that was specific and practical to help them make decisions about the likely cause of an illness, how to assess severity, and when to seek professional advice. They wanted to know of any implications of the illness or its treatment and the potential for prevention in the future. Most thought that being more informed would reduce rather than increase their anxiety.

In a literature review published in 2002 in the BJGP Hay and Wilson charted the progress of children under 4 who develop an acute cough:

At one week, 75% of children may have improved but 50% may be still coughing and/or have a nasal discharge. At two weeks up to 24% of children may be no better. Within two weeks of presentation, 12% of children may experience one or more complication, such as rash, painful ears, diarrhoea, vomiting, or progression to bronchitis/pneumonia.

The authors conclude that:

Illness duration may be longer and complications higher than many parents and clinicians expect. This may help to set more realistic expectations of the illness and help parents to decide when and if to reconsult.

By implication, as well as knowing when and how to investigate symptoms, it would help patients if doctors also routinely communicated the natural history of the commonest symptoms including and especially:

  • Acute cough
  • Acute low back pain
  • Rash
  • Depression
  • Sprain /strain

For example it has been demonstrated that the experience of individual doctors on this issue is unreliable. Writing on acute low back pain researchers from New Zealand suggests that 91% of patients stop consulting their doctor at 3 months after the pain starts and long before their symptoms have resolved. Also that only 1:5 patients are free of pain or disability one year after an acute episode of low back pain.

Picture by Tina Franklin

Am I going to be like this forever doctor?

There is an opportunity in nearly every medical interaction to make a substantial difference to the outcome by reassuring. What nearly every patient wants to know is:

How long will this horrible feeling last?

We can be reassuring in the various ways in which we conduct ourselves in healthcare. On the stage, with the props, in the persona we adopt, in the dialogue and in the action. All of it matters. Much of what appears on this blog speaks to these aspects of the consult.

People attend doctors for one main reason. They are worried. It doesn’t matter whether the cause is a minor self-limiting illness or a life-limiting cancer. Symptoms ultimately drive us to the medicine man. Here are the results of a study entitled ‘Why Patients Visit Their Doctors’:

We included a total of 142,377 patients, 75,512 (53%) of whom were female. Skin disorders (42.7%), osteoarthritis and joint disorders (33.6%), back problems (23.9%), disorders of lipid metabolism (22.4%), and upper respiratory tract disease (22.1%, excluding asthma) were the most prevalent disease groups in this population. Ten of the 15 most prevalent disease groups were more common in women in almost all age groups, whereas disorders of lipid metabolism, hypertension, and diabetes were more common in men. Additionally, the prevalence of 7 of the 10 most common groups increased with advancing age. Prevalence also varied across ethnic groups (whites, blacks, and Asians). St. Sauver et al

For each of these conditions it is possible to prepare a response that will reassure the person that things will improve.  It is interesting to read the lay commentary on the data:

What’s funny is that while skin disease is the most common reason for doctor visits in America, it’s usually the least detrimental to overall health……Pretty much everybody (and I mean everybody) has experienced a cold before. You know the symptoms; runny nose; coughing; sore throat; congestion. Due to the high volume of people who get colds every year (most people get multiple colds per year), it’s no surprise that some of those people will see the doctor about it. Therichest

And the implications of this commentary is that the response to patient is a ‘set-play’. Doctors and healthcare organisations can prepare to host a visit from most people who present for help. If you are a doctor what is your interaction like with someone with acne or eczema? How do you respond when this is the reason for attendance is a cold? What do you do? What do you say? Is that reassuring? How do you know? For most if not all these problems much of the treatment includes prescribing ‘tincture of time’ essentially that means reassuring the patient that they will not suffer forever.

There is evidence that such an attitude reduces the impact of the illness:

Clinician empathy, as perceived by patients with the common cold, significantly predicts subsequent duration and severity of illness and is associated with immune system changes. Rakel et al

Picture by Christophe Laurent

Are you addressing the right problem or the one you think you can fix?


The act of consulting a doctor has been shown to be highly ritualized.

Ritual has long been thought to play an important role in the healing processes used by ancient and non-Western healers. In this paper, I suggest that practitioners of Western medicine also interact with patients in a highly ritualized manner. Medical rituals, like religious rituals, serve to alter the meaning of an experience by naming and circumscribing unknown elements of that experience and by enabling patients’ belief in a treatment and their expectancy of healing from that treatment. John Welch. Journal of religion and health

There are five elements to this ritual:

  1. The stage- office, clinic room, cubicle.
  2. The props- what can be seen and or felt.
  3. The actors- doctor, patient and sometimes nurse or therapist.
  4. The script- what is said.
  5. The action- what is done.

All have an impact on the outcome. The doctor’s ‘script’ is of particular importance as it is what the patient hears. The literature offers evidence of the impact of what is said and how it is said on outcomes for patients:

 The quality of communication both in the history-taking segment of the visit and during discussion of the management plan was found to influence patient health outcomes. The outcomes affected were, in descending order of frequency, emotional health, symptom resolution, function, physiologic measures (i.e., blood pressure and blood sugar level) and pain control. M.A Stewart CMAJ

One conclusion of the literature review published in CMAJ was that the process of sharing information includes a discussion about what the patient understands to be the problem and their options with regard to treatment:

These four studies taken together debunk the myth that the only alternative to the physician’s total control of power in the therapeutic relationship is his or her total abdication of power. They indicate that patients do not benefit from the physician’s abdication of power but, rather, from engagement in a process that leads to an agreed management plan.

This issue assumes great significance when it comes to difficult consultations in which it is perceived that the patient is seeking an option that is not in their best interests. Greenhalgh and Gill wrote the following commentary in the BMJ in 1997:

Two thirds of consultations with general practitioners end with the issuing of a prescription. The decision to prescribe is influenced by many factors, to do with the doctor, the patient, the doctor-patient interaction, and the wider social context, including the effects of advertising and the financial incentives and disincentives for all parties. Hardline advocates of rational drug use do not look kindly on variations in prescribing patterns that cannot be explained by purely clinical factors. The prescriber who allows the “Friday night penicillin” phenomenon to sway his or her clinical judgment tends to do so surreptitiously and with a guilty conscience.

The team go on to conclude that:

The act of issuing a prescription is the culmination of a complex chain of decisions. It is open to biomedical, historical, psychosocial and commercial influences, no aspect of which can be singled out as the ”cause” of non-rational prescribing. The search should continue for methods to measure the interplay of these disparate factors on the decision to prescribe.

Michael Bungay Stanier offers an approach to business coaching by focusing on what a person perceives to be their challenge, what they want and how that choice might be impacting on their other options. A similar approach can be taken in medicine. Two decades after Trish Greenhalgh’s editorial in the BMJ there are still many circumstances in which doctors find it challenging to negotiate options these include but are not limited to:

In this context our team surveyed nearly 9000 patients who had been prescribed antibiotics for Upper Respiratory Tract Infections during the latest flu season. We surveyed patients using a validated tool on the third day and the seventh day after a prescription was issued. We look forward to presenting the results at the forthcoming GP17 conference. We will be offering information on the following questions:

  1. What is the profile of patients who were offered a prescription?
  2. What was the symptom profile at these time points and how does this compare with data on patients who have been offered no treatment in other studies?
  3. What are the characteristics of the respondents to the survey?
  4. What proportion of respondents completed the course of treatment?
  5. What proportion of respondents also took regular symptomatic measures?
  6. What is the profile of patients with relatively severe symptoms at each time point?
  7. Are longer consultations or type of antibiotic predictive of compliance with treatment?
  8. Within the limitations of a study that offers only the patient perspective what might help people with Upper Respiratory Tract Infections?

Picture by US Army Garrison Red

A cough is not minor in any sense

 

 Acute cough, which often follows an upper respiratory tract infection, may be initially disruptive but is usually self‐limiting and rarely needs significant medical intervention. Thorax

In adults or children with acute cough, the evidence does not support the effectiveness of over the counter preparations. Cochrane Review

On the other hand:

Oral syrups segment is expected to expand at 2.9% CAGR (Compound annual growth rate) over the estimated period and be valued more than US$ 10 Bn by the end of 2026. The segment is expected to create absolute $ opportunity of a little more than US$ 300 Mn in 2017 over 2016. The segment is the most acceptable dosage form for cough, cold, and sore throat medicines due to ease of administration and pleasant taste. The oral syrups segment dominated the global cold, cough and sore throat remedies market in terms of revenue in 2016 and the trend is projected to continue throughout the forecast period. Oral syrups segment is the most attractive segment, with attractiveness index of 1.5 over the forecast period. FMI

Cough, cough, cough. Every hour on the hour. There appears to be no end to it this season. No symptom is driving more people to seek treatment than the misery of upper respiratory tract infections (URTIs). The impact of the URTIs season on the population is massive as has been demonstrated in data from the US:

More than half (52%) of Americans reported that their cold impacted their daily life a fair amount to a lot. Productivity decreased by a mean 26.4%, and 44.5% of respondents reported work/school absenteeism (usually one to two days) during a cold. Overall, 93% of survey participants reported difficulty sleeping. Among all respondents, 57% reported cough or nasal congestion as the symptoms making sleep difficult. Drug Store News

One issue that appears to be bound up with the epidemic of URTIs is rates of prescribing of antibiotics. Here the available data are encouraging:

Professor Bell suggests that 20–25% of acute URTIs are likely to need antibiotics…..We have shown that over the last 13 years GPs in Australia have decreased their level of prescribing of antibiotics for acute URTI and to a lesser degree, for ‘other RTIs’. Britt et al

However there is an opportunity here over and above the treatment of an annoying self-limiting infection. Most people who seek help want more than anything else to feel better. By 2026 they will spend $10Bn in the attempt. The conversations in consulting rooms and pharmacies around the country focus on symptoms that will improve, eventually. Antibiotics won’t help. But, in the end what people want is to feel better not a lecture on virology. There is an opportunity for a ‘set play’.

Yes, you have a nasty infection and I see that it is making you miserable. Here’s what you can do to help your self.

There is an opportunity to forge a relationship with the patient. The ritual of the consultation complete with examination has the potential to create enormous deposit of social capital. Something that might be critical when the patient presents later in life with life-limiting pathology. There is the chance to understand a lot more about the patient for whom a cold is the final straw. But what’s the context? Be curious, very curious that’s why it’s called the art of medicine.

Picture by Rebecca Brown

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