Options without admitting: \200 Neighborly help \200 Hospice \200 Sheltered housing \200 Hospital at home \200 Nursing/rest home \200 Social services home \200 Twilight home nurses \200 Domiciliary physio/OT \200 Admission avoidance team \200 Fast-respo nse nursing Empowered self-care entails choice (p315), dialog (p370), knowledge of mental states (p324) , informed consent (p402), literacy/education (p494), par- ticipation in planning and respe ct by professionals for lifeworlds other than their own (p321). We have to harmonize our ca re-plans with patients \200\231 belief systems. So if a man takes strength from meditation, this should feed into the dialogs which inform his empowered self-care. This yields more p atient satisfaction and improved outcomes (such as improved health, reduced pre- scribing, fewer side eff ects, etc): see p517. 22 \200\22325 Barriers to this type of care \200 Peo ple who are rendered helpless and hopeless by unemployment, poverty, and family strife. Oth ers who have diffi culty accessing care include: the homeless, refugees, drug abusers, ethn ic minority groups, and patients liv- ing in rural areas without public transportation. Professionals who want to monopolize and medicalize health. \200 Nations which are keener to take up arms than to vaccinate them. \200 A world which behaves as if it does not kno w the meaning of social justice and equality, and in which rich and poor fail to share comm on objectives \200\224 or simply fail to share anything. Primary health care teams Whenever a task can be successfully delegated, delegate it. The a ntithesis is: If you want a job done properly, do it yourself. Nature favors the \201 rst maxim: when we die all our tasks are either forgotten or delegated, often by default. So t he question is not whether to delegate, but when, and to whom. The principle of team work i s: No member is indispensable; all can contrib- ute. Teams may be small and close-knit, or large \200\224for example the NHS \200\230super surgery \200\231, with doctors, dentists, opticians, a drugstore, and heart clinics.et al Doctors Principals/partners: GPs holding co ntracts with a Primary Care Or- ganization (PCO) and consortia; some may specialize (eg end oscopy), or have a role in the PCO, eg in commissioning care;1 GP non-principals, sessional GPs locums; FY1, ST3 registrars. Medical and other students may also be present. 474 A good question for any partnership to ask is \200\234What is our range of skills, and is postgraduate training being arranged to \201 ll in any lacunae? \200\235 GPs with special interests need not undermine the central role of being a generalist. Community nurses (emp loyed in England by Primary Care Trusts). Activi- ties: post-op visits for dressings and th e removal of sutures, dressing leg ul- cers, and giving \200\230all care \200\231 to the d ying, giving injections (eg to blind diabetic patients), and supplying incontinence and oth er aids catheterizations. Nurse prescribers have additional training and are termed Inde pendent or Supple- mentary Nurse Prescribers (SNP). SNPs only prescribe according to protoc ols once a diagnosis has been made. 26 Midwives They do antenatal classes, clinics, home vi sits, and home deliveries. They have a statutory obligation to visit in the puerperium for the 1st 10 days (she has right of access). At 10 days the health visitor takes over. Health visitors have nursing and midwifery backgrounds, plus health visiting quali \201 cations. Roles: developmental testing of children; immunization advice; breastfeeding; minor illnes s in children; handicap; advice to adults about diet & smoking; implementing health educati on offi cer (p495) strategies; screening of the elderly in their homes; bereavement visits. Practice nurses activities include: \200 Tests: Urine; blood (best delegated to a phlebot omy-trained receptionist, with a \200\230health assistant \200\231 role); audiometry; ECGs ; peak \202 ow. \200 Advice: Diet; travel. \200 Treatment: Ear syringing; injections. \200 Prevention & audit: Vaccinations; BP; cervical smears; family planning/IUCDs (eg holdi ng an English National Board Certi \201 cate). \200 Chronic disease: Diabe- tes, asthma, COPD, heart disease, etc. \200 Chaperoning: Usually she is too busy. Nurse practitioners d iagnose and initiate treatment. Patient satisfaction is high. No increase in adverse outcom es has been found; consultations are longer by 3 \200\2234 minutes, and more tests are done . 27,28 Community matrons have case-loads of 60 vulnerable patients, eg with multiple path ologies such as CCF and falls. She gives home care (active case management) aiming to \200 \201emergency admissions (which fall by 6% on the most optimistic forecasts). 29 Counselors 30% of GP patients have psychological conditions, and to help with these, counselors may b e employed; their role is uncertain (p381). Receptionists and secretaries Receptionists may take on a health assis- tant role taking blood, testing urines, doing BPs, capillary gluco se, ECGs, or au- dits (have they had their hepatitis B vaccinations?) Practice managers lea d on: \201 nance; employment law; tax; risk assessment/ reduction; health & safety; audit ; commissioning care contracts. Others: So- cial worker, psychologist, physiotherapist. Bey ond the surgery: NHS Direct; NHS walk-in services; nurse-led personal medical services; com munity phar- macists, health education offi cers (p495), community physicians. e r a c y r a m i r P 1 Commissioning care may seem something you are not engaged in, but every time we sign a pr escription we are commissioning care, and we all need to take responsibility for how money is spent. 475 Small practices vs huge commercial companies Commercial primary care companies (eg The Prac tice , under contract to the NHS, 30 with loyalties to shareholders, not the communities t hey serve) are new in UK primary care, but polyclinics have long existed in India, Germany, Russia, France, and USA). 40 or more primary care doctors work with dentists, mid- wives, nurses, physios, radiologists, chiropodists, endoscopists, and consult- ants. They aim to d o half the work now done in hospital. Their champions say they are: \200 Cheap \200 Mor e integrated (easy to refer across the corridor) \200 Better equipped \200 Available ou t-of-hours (24/7). But continuity of care suff ers; this is highly valued by patients, 10 a nd gives much job satisfaction to GPs. An example shows the value of continuity of care. One of us (JML) was called to an unrousab le sweating 60-year-old man, whom we admitted to hospital with suspected septicaemia \200 \224which, years later, turned out to be the present- ing symptom of an occult, indolent ma lignancy. We looked after him until his death at home. The continuity of care, not the clin ical details, made the job interesting. But the continuity doesn \200\231t stop at the end of one life. Now, when- ever we see his wife, on trivial and grave problems, we have this s hared bond. When she refused hospital admission for pneumonia and hypoxia, we could use thi s shared bond to induce her, over a day or so, to change her mind. e r a c y r a m i r P The dangers of exhaustion and isolation are not solved by larger practices or polyclinics ( which could add to professional isolation). NB: single-handed doctors are more likely to co mpensate for isolation from colleagues by identi- fying more with patients, which may well help patient centered care. I am now about to start a day of single-handed general practice as my part- ner is away. Th e day is unplanned, the appointments book empty. People just turn up, bringing their infarc ts, their sorrows, their trivia, and their life events to me. Some of the people who will c ome have not yet even fallen ill. There are the coronary artery plaques on the point of rup turing, the dizziness before the fall, the hallucination before its enactment, and someone is now writing a note to explain the impending suicide or the fact that they are leaving ho me forever, and taking the kids with them. All this is in the future; but for now, none of this has happened yet. I am completely up to date, and I command my general practice sittin g behind an empty desk. I saw the last person who wanted to see me yesterday. There is no w aiting list. Just the unknown. When the patient \200\231s dizziness does lead to the fall i n the village shop, as it did yester- day, I will be on hand to patch up the old lady, and the receptionist will kindly \201 nish off the patient \200\231s shopping for her, and es cort her home. Problems with large clinics Think-tanks (eg the King \200\231s Fund31) focus on: \200 Access problems, not just in rural areas. People don \200\231t want to go 20 mi les to see any old doctor rather than \200\230my doctor down the road \200\231. \200\207B ut big clinics might be just what \200\231s needed in inner city areas if current premises are poor. \200 Planned economies of scale cannot be relied upon. Consultants traveling ti me are much increased, and demand on hospital services may rise, not fall. \200 Studies s how that bene \201 ts of one-stop care often fail to materialize, eg the diabetologist is too busy to see Mrs Salt \200\231s foot today. Tomorrow it is worse, and there is no vascul ar surgeon on site, so admission is needed anyway. \200 Smaller establishments do better, generally, in terms of quality of care. \200 Problems with leadership which make working together harder not easier. \200 Co-location doesn \200\231t necessarily lead to co-work ing and good team dynamics. \200 Effi ciencies in the USA where specialists work from iso lated offi ces will not accrue in the UK where specialists already work together in hospita l teams. A compromise \200 Less pure models of polyclinics have been toyed with in some co untries, and in the UK allow GPs to retain their premises and share ex- tra facilities for diagnosis/treatment. This model meshes with the RCGP Road- map, 32 but funding issues are u nresolved. The busy GP stereotype and patient-centered care 3 views: 476 1 No one is busier than a GP: the busy GP is a typical role model and stereotype. 2 This \200\230busy \200\231 thing isn \200\231t a commitment: it \200\231s an evasion. Sebastian Faulks Engleby page 155 3 Patients are busy too: The DoH calculates that 3.5 \211\210106 wo rking days are lost queuing to see GPs (this assumes queuing patients were well enough to w ork). Hence the move to walk-in supermarket health centers: see p507. As the list of tasks to do in consultations lengthens, patient \200\231s own needs get crowded out. Depressed pa tients, for example, frequently hold back informa- tion they would like to discuss, as the doctor seems too busy. Does this mat- ter? It does if your aim is patient-centered care (p4 78). One study shows that far from doctors having a patient-centered approach it \200\231s usually the other way around \200\224the patient has a doctor-centered approach, and is alt ruistically keen to conserve scarce resources. 33 This concern about \200\234not worrying the doctor \200\235 can be counterproductive. So every so often try saying \200\234Take yo ur time \200\224I \200\231m not in any hurry. Let \200\231s try to get to the bottom of wha t \200\231s going on \200 [pause] \200\235. Time and the consultation Consultation times have risen by 40% since 1992 (now 12min). 34 Short consultations are riskier than longer o nes (eg less time to look things up 35 and for safety netting \200\234If x, y, or z develo ps, come back sooner \200 \200\235), but they are frequently unavoidable. \200\207Does he avy demand pro- duce short consultations, or do short consultations produce heavy demand by failing to meet patients \200\231 needs? GPs \200\231 average consultation time is 7min ( with some consultations lasting hr). This seems short, but remember that over a year the time spent with each patient is nearer 1h. The consultation time in \202 u- ences the deg ree of patient satisfaction, and may in \202 uence the consultation rate (in the UK, 5.5 consultations1/person/yr, rising by 4%/yr), 36 with lower return visit rates for longer co nsultations (not shown in all studies), 37 lower rates of prescription issue (esp. antibiot ics), and more preventive activities. Mean face-to-face consultation time is 8min for 10min appointments but only 9.2min for 15min appointments, suggesting extra time may not be well used by doctors when booking intervals are long. Running late is stressful for doc- tors ( and patients): it is easier keeping to time for 10min (rather than shorter) bookings. Other factors apart from season, distance to the GP, and sex (women consult more than men) which increase ( \200\200) or decrease ( \200\201) consultation rates: \200 Low frequency of c ontact associates with \200\200educational status, 38 paid employ- ment in the health sect or, and low expectations of GP care for minor illness. e r a c y r a m i r P The cheaper the housing (council tax bandUK) the higher the consultation rate. 39 \200 Li st size, and having personal lists (consultation rate \200\201 by 7% \200\224ie patients a re encouraged to consult with only one doctor decreases overall attendance). \200 Not pre scribing for minor ailments \200\224see p517 (? \200\201). \200 New patients (for their 1 st yr with a new GP), and patients over 65yrs ( \200\200).2 \200 If the GP is extrovert ( \200\200) he or she recalls more, and his rate is higher than others (eg 6/yr vs 2/yr). GP age and sex also in \202 uence rates. \200 High latitudes \200\224within the UK ( \200 \200). The South-East has lowest rates. \200 Social deprivation ( \200\200) and morbidity ( \200\200). 40 Increasing requirements to moni- tor almost all diseases and drugs, eg sha red care of rheumatoid arthritis ( \200\200). \200 Preventive activities ( \200\200; but this can reduce need to invite people to clinics). There is some evidence 37 for the Howie hypothesis41 that consultation duration is a valid and measurable marker of quality (eff ec tiveness, safety, equity, and holistic patient experience, p327 & p517). It is certainly no t true that extending consultation times will automatically increase health and satisfactio n. 37 1 34% by nurses; 62% by GPs; 82% are in surgery; 12% by phone; 4% home visits (9% in 1995); few by email. 2 If \200 , the UK consultation rate at 10yrs old is 2.4/yr; at 20 i t is 5/yr, at 80 it is 7/yr. If \200 , the consulta- tion rate at 10yrs is 2/yr, at 20 it is 1.7/yr, at 50yr it is 2.7, at 70 it is 5.6, at 80 it is 6.7/yr. A GP with a list of 200 0 with 300 patients >65yrs will have provided 210 more consultations to this group in 1998 than in 1992. This trend continues beyond 2002, it is believed. 4 2 477 Phone consultations: saving time or creating problems? Phone consultations/triage (p797) se em a tempting way to reduce need for precious appointments, and hence improve access (max w ait \211 2 working days). What is the evidence? During phone consultations, most non-verba l cues are missing. To explore this issue in a practical way, try consultations with friend s or actors with whom you are sitting back-to-back. One way to improve these consultations is to do more \200\230explicit categorization \200\231, eg \200\230First I am going to \201 nd out more about how you are now, then I \200\231ll ask about your drugs, then I \200 \231ll go over what I can do to help, then what to do if things get worse. \200\231 Research shows that use of phone consultations in place of same-day, face- to-face consulta tions does save time, but is often off set by higher re-consulta- tion rates and less use o f opportunistic health promotion. 43 e r a c y r a m i r P Safety of phone triage by nurses may be poor; urgency was correctly as- sessed in 69%, and underestimated in 19%. 44 Results may be better with computer-aided decision support: in on e study, advice was considered OK in 97.6%. Patients \200\231 compliance: Self-care \200 \22481%. \200\234Go and see your GP \200\235 \200\22491%. \200\234Go to A&E \200\235 \200 \224100%. Saving per call: 70, 24, and 22 respectively. 45 Phone counseling of non-treatment-seeking primary care patients with al- cohol abuse works: the higher the number of calls, the less risky the pattern of drinking. 46 Mobile phones o ff er greater \202 exibility, and are a valid method in treating school refusal (p212) an d in telemanagement of diffi cult hyperten- sion and diabetes (Blue Tooth transmission of ambulatory data). 47 From medical certi \201 cation to living wills: all the GP forms Inc apacity/sick pay We despatch the metaphysical job of deciding who is well and who is sick, and for how long, with amazing (but spurious) preci- sion: appendicectomy \211\210 2 \200 \2233 weeks; CABG \211\210 6 weeks; MI \211\210 5 weeks; cholecys- tectomy \211\210 2 we eks (5 weeks if open); laparoscopic inguinal hernia \211 2 weeks (with driving; longer wit h older techniques). Form med3: see p522. Form MatB1 gives a pregnant woman time off work once she is 20 weeks before the expected date of delivery (signed by a GP or midwife). Lasting power of attorney 48 This passes legal authority over \201 nancial, health, and welfare aff airs to a name d person, who can then sign checks etc for another person. It holds good, eg if the patient has a stroke or dementia if the patient had capacity (p403) at the time it was made. 49 Li ving wills Practices may keep advance directives limiting care a patient will accept after a mentally incapacitating illness, eg stroke. They have claus- es such as \200\230If I hav e a stroke and there is little prospect of recovery, I decline to be tube fed, even if this hastens death. I understand what tube feeding is; it has been explained to me by my GP, Dr \200 on [date], and it is my considered, enduring wish that \200 \200\231 These document s have legal force. We must record their existence in the notes, and act on them. Patients don \200\231t have to be dy- ing for the will to be triggered, and they may prohibit life-s aving treatments. Patients send copies to the family and solicitor. 50 Knowing a person \200\231s wishes makes it easier for relatives to make diffi cult decisions. 51 The consultation The consultation is the central act of medicine: all else derives from it. We must acquire \202 air for telling which part of which model is vital or dangerous at any time, so that in busy surgeries with urgent visits mounting up, both the doctor and his or her patients can survive. Medical model History \200\203examination \200\203tests \200 \203diagnosis \200\203treatment \200\203review. A patient-centered model52 \200\2059 stage s ( \200\207depending on the patient \200\231s wish) 1 The GP encourages patient contributi ons and communication. Preconsulta- tion lea \202 ets encouraging questioning and airing o f concerns help here. 52 2 The GP elicits patient \200\231s desire for information; knowing this, the GP decides to be brief & authoritative or re \202 ective. \200\207The patient leads this process. 53 3 The GP may set the patient \200\231s complaint in social or psycho logical context while exploring and testing his or her ideas, concerns, expectations, and h ealth beliefs. These beliefs are used to explain diagnosis and treatment. 4 The GP gets suf fi cient information for no serious condition to be missed. 5 Physical exam either addresse s patient \200\231s concerns, or con \201 rms or refutes hypotheses generated by the histo ry, leading to shared working diagnosis. 478 \200 6 The patient participates in the planning of treatment in the light of EBM. 7 Concordance (p519) discussions; patient sets his own target BP, HbA1c etc. 54 8 The medical record entr y may be something the patient wants to agree. 9 Establish rapport with the patient at all stages \200\224and arrange follow-up. The Stott & Davis model 55 e r a c y r a m (other models: www.skillscascade.com/models.htm) i r P Managing presenting problems Managing continuing problems Modifying help-seeking behavior Opportunistic health promotion A hypothesis-testing model Information is collected and its validity is as- certained by ge nerating and testing hypotheses. Goal models (ie ends matter, not means) Aim to: \200 Cur e; comfort; calm; counsel; prevent; anticipate; explain. \200 Enable the patient to put h imself back in control of his life. \200 Manipulate society to the patient \200\231s adva ntage. \200 Facilitate change where change is what the patient desires. \200 Increase p atients \200\231 stature \200\224by tapping the sources of richness in their lives, so freeing them from the shadow of insoluble problems. Roger Neighbor ISBN 0-7462-0040-4 The inner consultation 1 Connecting is the process of establishing rapport. 2 Summarizing m arks the point at which the patient \200\231s reasons for attend- ing, his hopes, feelings, concerns, and expectations have been well enough explored, acknowledged, and summarized fo r the consultation to progress. 3 Handing over follows the doctor \200\231s assessment and diagnosis of the presenting problems and entails an explained, negotiated, and agreed manag ement plan. 4 Safety netting allows the doctor the security of knowing that she has pre- pa red, or could prepare for, contingency plans to deal with an unexpected event and some depa rtures from the intended management plan: see p532. 5 Housekeeping allows the GP to deal with any internal stresses and strains. The hidden con sultation Doctor-drivers that we may prefer to hide: 1 Keep to time at all costs: I must en gineer an exit in the next 2 minutes. 2 Keep control: eliminate any space for undisciplined squads of emotions. 3 Defensive medicine: do tests/refer onwards to lessen the risk of a c omplaint. 4 Reframe/retell/lie to make the history \201 t criteria of a service you can r efer to. 5 Don \200\231t rock the boat: do whatever a patient asks. \200\234Refer me for M RI \200\235 \200\234Yes sir! \200\235 6 Make money: more income-generating tasks irrespect ive of health gains. How to avoid these? Don \200\231t practice medicine in the 21st-centur y; don \200\231t cede con- trol to large organizations; and above all, don \200\231t worry. \200\207Doctor-neurosis is the single biggest obstacle to health in almost every consulta tion. 56 \200\22358 479 In consultations that are going wrong \200 Ask yourself \200\234Am I granting as much spa ce to the patient \200\231s agenda as to mine? \200\235 This is a particular problem with G P contracts which demand attention to back- ground diseases \200\224eg patient: \200\234I \200\231m worried about my husband \200 \200\235; GP: \200\234OK, I \200\231m going to t est your vibration sense and pulses \200 \200\235 \200 \200\234Have I discovered his ho pes and expectations, and his fears? \200\235 Does this matter? Yes! Congruence of illness representation leads to better commu- nication, better adherence to advice, and better pati ent satisfaction. 59 \200\22360 \200 \200\234Am I negotiating openly with the patient ov er our clashing ideas? \200\235 \200 \200\234What are my feelings, and how can they be u sed positively? \200\235 \200 Try saying: \200\234Things aren \200\231t going very well. Can we start again? \200\235 Perceptual \201 lters, decision analysis, and unconscious c onsulting When decision-analysts started work observing consultations they were amazed at t he number of decisions per minute, and the wide range of pos- sible outcomes, such as \200 \230no action; review next week \200\231 or \200\230blue-light ambulance direct to tertiar y referral center \200\231 or \200\230refer for EEG \200\231 or \200\230prescribe X, Y, a nd Z, and stop Q in a week if the blood-level is such-and-such \200\231. The average decisi on- analyst is disorientated by the sheer pace and apparent eff ortlessness of these decisi ons \200\224so much so that doctors were often suspected of choosing plans almost randomly, until the idea of a \200\230perceptual \201 lter \200\231 was developed. Perceptual \201 lters 61 This is the internal architecture of our mind \200\224unique to each doctor \200\224into which we receive the patient \200\231s history. It comprises our: \200 Uncon scious mental set: tired/uninterested to alert, engaged, responsive. \200 Entire educatio n, from school to last night \200\231s postgraduate lecture. \200 Sum of all our encounte rs with patients. Ignore the fact that we can re- call very few of these: this does not sto p them in \202 uencing us strongly: does the rock recall each of those many, many waves wh ich have sculpted it into extraordinary shapes, or which have entirely worn it away? e r a c y r a m i r P Past speci \201 c, personal experience with this particular patient. \200 Past speci \201 c, personal experience with the disease(s) in question. \200 Non-personal subjective (eg \200\230endocarditis is the most dangerous and stealthy disease \200 \200\231) or ob jective ideas (eg evidence-based medicine, p489). The mind \200\231s working space (random access memory, RAM) 62 The percep- tual \201 lter achieves nothing on its own. What is ne eded is interpretation, rear- rangement, comparison, and planning of executive action. Feedback loop Information sources Perceptual \201lter Working space Memory Interpretation Rearrangement Comparison Risk computation Planning of executive action History Examination Test results Education Experience Scienti \201c medicine Life events Long-term memory with various logical and non-logical relationships Storing Retrieving Fig 1. Consultation \202 owchart. After Sullivan. 61 \200\207The abilities of our mental working space are determined by the number of items of data that can be integrated into a decision. There is evidence 63 that this vital number is 3 \200\2238. The interesting exper imental point here is that if we overload our RAM in the consultation by recourse to a draw er full of guidelines, or un \201 ltered information \200\224eg looking things up in an un structured textbook, performance may decline. 63 As one juggler said (with 6 balls in the a ir) \200\234How do I do it? \200 If I did know what I \200\231m doing I would not be abl e to do it. \200\235 64 Consultation analysis It is a sad fact that we lose some of our innate skills in communicat ing while at medical school. Consultation analysis aims to revive and extend this art, and we know it brings permanent improvement in those who participate. But do not conclude from this that research into the perceptible surface of behavior can ever fully show us what is happening in the consultation.1 65 Methods The \201 rst step is to gain the patient \200 \231s consent. The method which gives the most information and the most scope for learning employs an ob- server/director sitting behind a 2-way mirror, who can pass verbal instruc- tions to the doctor through an earphone which is worn unobtrusively. The activity is videoe d for later analysis. By directing the verbal and non-verbal behavior, the observer can dem onstrate the potential of a consultation in ways that the doctor may not have imagined poss ible. Other methods include simple video or audio recording, and joint consultations, in wh ich the second doctor either participates in or observes the \201 rst doctor \200\231s co nsultations. 480 \200 Consultation analysis is likely to be a somewhat threatening activity, so rules have been e volved to minimize this. 66 For example, facts are discussed before opinions, the consultin g doctor says what he did well, and then the group discusses what he did well. Then the con sulting doctor says what he thinks he could have done better, and \201 nally the group sa ys what he could have done better. In practice, these constraints are occasionally stultify ing, but it is better to be stulti \201 ed than hurt. Mapping the consultation and scoring its eff ectiveness In the consulta- tion mapped below, the patient \200\231s inferior myoc ardial infarction (sudden chest pains on swallowing hot \202 uids) was mistaken by the do ctor (JML) for indiges- tion, illustrating that there is no point in being a good communica tor if you communicate the wrong message. It also shows how misleading it is to add the sco res (50/84, but the patient nearly died). e r a c y r a m i r P Fig 1. Mapping a consultation. 1 This paper uses concordances of serial consultations to investigate such things as the pl ay of power in doctor/patient relationships, and shows that the old schools of behavior-bas ed and meaning-based analysis need not be mutually antagonistic. 67 \201\201 On the impossibility of being a good doctor Here is a list of some of the things pundits tell us we should be doing when we meet patients 68 (don \200\231t get depressed ye t: we promise there is a solution). 1 Listen \200\224no interrupting or taking control of t he agenda (how often are we 481 guilty of implying: \200\234Don \200\231t talk to me when I am interrupting you \200\235)? 2 Examine the patient thoroughly (a nonsensical idea, or at least, so it would seem to the average patient with sciatica when you ask them to name the parts of a clock, or to pronoun ce \200\230The British Constitution \200\231). 3 Arrange cost-eff ective investigation (via Google or a trip to the library if needed). 4 Formulate a diff erential diagnosis in social, psychological, and physical terms (a famou s triad, no doubt, but why exclude spiritual, allegorical, materialistic, metaphysical, and poetic dimensions of the consultation?). 5 Explain the diagnosis to the patient in simple terms (then re-explain it all to relatives waiting anxiously outside, and then try re-expla ining it to the computer in terms it understands \200\224ie 5-digit Read codes). e r a c y r a m i r P 6 Consider additional problems and risk factors for promoting health. 7 List all the treatm ent options, and seek out relevant systematic reviews, guidelines, clinical trials, etc (evidence-based bedside medicine). 8 Incorporate the patient \200\231s view on the balance of risks and bene \201 ts, harmo- nizing his view of priorities, with your own assessment of urgency. 9 Arrange follow-up and communicate with all of the health care team. 10 Arrange for purchase of all necessary car e, weighing up cost implications for your other patients and the community, welcoming accou ntability for all acts and omissions, and for the effi cient use of resources \200\224with jus- ti \201 cations based on explicit criteria, transparency, and principles of au- tonom y, non-male \201 cence, bene \201 cence, and distributive justice. The alternative Look the patient in the eye. Look the disease in the eye, and then do your best. The synthesis The alternative looks promising \200\224even attractive, when com- pare d with the 10 impossibilities above. But note that the alternative only looks attractive be cause it is vague. \200\230Do your best \200\231 is not very helpful ad- vise \200\224and once we start unpacking this \200\230best \200\231 we start to get a list like the 10 impo ssibilities. \200\230Professionalism \200\231 sums up part of what being a good doctor ent ails \200\224ie \200 Self-regulation \200 Self-actuating and self-monitoring of standar ds of care. \200 Altruism \200 Commitment to service \200 Specialist knowledge and te ch- nical skills re \202 ecting but not determined by society \200\231s values \200 Cons istently working to high standards of probity and quality (no bribes, no favoritism, but a dynamic concern for distributive justice). \200 Self-determination vis vis the range a nd pattern of the kinds of problems it is right for it to attempt to solve. For a further d iscussion, see On Being a Doctor: Rede \201 ning Medical Professionalism for Better Patien t Care (King \200\231s Fund). Trying to achieve authenticity is a meta-goal, and may be a better mast to nail your colors to than the 10 impossibilities above not because it is easier but be- cause paying attenti on to authenticity may make you a better doctor, whereas striving for all 10 of the impossi bilities may make you perform less well (too many con \202 icting ideals). With inauthenti c consultations you may be chasing remunerative activities, quality points, protocols, or s imply be trying to clear the waiting room, at any cost, while the patient is trying to twis t your arm into giving antibiotics or a medical certi \201 cate. Authentic consultations a re those where there are no barriers; just 2 humans without status exploring and sharing hy potheses and beliefs and deciding what to do for the best (along the lines de- scribed in d etail on p531) \200\224with no ulterior motives and no con \202 icts of interest. Authenti c consultations know and tell the truth where possible, and where this is not possible, the truth is worked towards \200\224diligently and fearlessly. Prevention The bene \201 ts of preventive activities are often uncertain: the only certain ty is that harm will be caused to some people. The discipline of quater- nary prevention (B OX) aims to minimize this. Prevention through the human life cycle Pre-conception (p2). Is she using folic acid supple- ments? Is she rubella immune? If not, vaccinate, and ensure ef f ective contraception for 1 month after vaccination. Is she diabetic? If so, optimize glyc aemic control as early as possible (p3, 24). Child: Vaccination (p151); hearing; safety les sons; developmental tests (p218); heart disease, p156. Preventing myocardial infarcts: See the UK National Service Framework for heart disease. 69 Smoking trebles risk above the rate for men who have never smoked. Systolic BP >148mmHg (40% of men) doubles risk,1 and if ser um choles- terol is in top 20% of the observed range, risk trebles. Help to stop smoking (p 512), and treat- ing hypertension (OHCM p134) & dyslipidaemia (OHCM p704) are the main inte rventions. GPs/ practice nurses have a central role in preventing cardiac deaths, eg by scr eening for \200\200BP, and en- couraging less smoking \200\224and giving statins (not base d on a particular cholesterol level, but ac- cording to overall risk of MI and stroke).2 Pr eventing breast cancer deaths: Education and \200\230breast awareness \200\231. Mammograph y ( \200\230neg- ligible \200\231 radiation): cancer pick-up rate \211\210 5/1000 \200 \230healthy \200\231 women. Yearly 2-view images in post- menopausal women might \200\201m ortality by 40%, but the price is serious but needless alarm caused: ( 10 false +ve results for each true +ve result). The NHS off ers 3-yrly single views to those between 47 and 73 years old (older wom- en may be screened too). Prevention in the reproductive years (p488): Safe sex education (start at pu- berty; teaching to use condoms need not increase rates of sexual activity); fam- ily planning (p296 \200\223306), antenatal/prenatal care (p2, eg fo lic acid), screening for cervical cancer (p270), blood pressure, rubella serology. Preventi ng oxidative damage by free radicals: Antioxidants, eg vitamin E, C, carotenoids, \202 av enoids, and selenium (OHCM p693) may have a role. 71 Old age: \200\230Keep \201 t \200 \231, pre-retirement classes, bereavement counseling, falls clinic. The main aim is to adop t the measures above, to ensure that there is an old age. Side eff ects No intervention is without side eff ects, and when carried out in large populations the problems may outweigh the bene \201 ts. Smoking and prevention: p512. Seat belts and prevention: p791 482 \200 Examples of prevention Primary prevention: (preventing occurrence) \200 Vaccination \200 Quit smoking advice \200 Binge drinking advice \200 Healthy eating advice \200 Safe (r) sex advice (HIV) \200 Hypertension screening \200 Preconception folic acid to prevent spina bi \201 da Fluoride in water (caries) Secondary prevention: (screening for 1st stages) \200 Cervical cytology \200 Mammography \200 Proteinuria in pre-eclampsia \200 Microalbuminuria in DM \200 Colonoscopy for polyps \200 Densitometry (osteoporosis) \200 Diet advice in impaired fast- e r a c y r a m ing glycaemia Tertiary prevention: (preventing complications) \200 Aspirin after a stroke \200 Retina l photography in dm \200 Hip protectors after falls \200 \200\230Don \200\231t go bare foot \200\231 (diabetes) \200 Vitamin D in osteoporosis Metaprevention (or quaternary pre vention): \201\201 Preventing medicalization \201\201 Prioritizing preventive i r P options \201\201 Shielding from over-zealous prevention, eg no ACE-i for heart protection if prone to postural hypotension/falls. 70 1 Reversible with antihypertensives and a statin (even if cholesterol \200\230normal or lo w \200\231); ASCOT study. 72 2 The Heart Protection Study (HPS) indicates that if a patient has vascular risk factors, eg family history, obesity, sedentary life, smoking, \200\200B P, DM) statins can be of bene \201 t even if lipid levels are considered OK. In HPS (N=20, 000) overall risk of MI & stroke was \200\201 by 30% in those on simvastatin 40mg/24h. Sta tins also \200\201 risk of getting angina, the need for angioplasty/bypass, and amputation s. Advantages hold good for women and men, and those over 70. 73 The AFCAPS/TEXCAPS study s hows that treatment can \200\201 adverse coronary events even in the primary prevention of patients with normal cholesterol levels and no risk factors (past MI etc). 74 \200\22376 This page intentionally left blank Barriers to prevention Genetic barriers Not everyone responds to preventive measures. Some