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Why should you always examine the patient?

In the second question in our two-minute question series Dr. Moyez Jiwa, host of the Health Design podcast asks if the clinical examination is a crucial part of the experience when visiting a doctor.

The respondents have all been featured in our podcasts. You an hear the longer conversations here:

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Telehealth is not fit for purpose in primary care

As a response to Covid-19 in Australia there is the scope to consult a doctor by telephone or video. The appointment is scheduled at a specific time and the doctor will ask your name, date of birth and address to confirm your identity. Some practices will offer these consults to people who are not eligible for the government rebate for a private or insurance fee.

The type of problems presented to doctors vary from acute to chronic illness. There might be requests for repeat medications or a discussion about test results. Reflecting on the variety of problems presented it is evident that in many cases people are seeking to talk to doctors about issues that need a face to face appointment to be managed safely.

Do you know what this tiny red spot is on my eye lid?

I just want a referral to a psychologist. I don’t want to talk about why on the phone.

My two year old daughter had a rash yesterday. It’s getting better I just need a note to say she can go back to child care.

I think I’ve got meningitis, but it’s getting better today. What do you think?

I had a migraine yesterday and need a day off work.

I think my daughter has nappy rash.

I’ve got iron deficiency anaemia. Another doctor far away did the test for me. I don’t like eating meat and I don’t like taking iron tablets. I’ve googled it and I want a injection of iron. Please leave a script at the desk for me.

It may be true that the patient should not travel to the clinic if possible to reduce any risk of infection. On the other hand it may also be true that the convenience of having an appointment when it suits has made it all too tempting to present problems that need an in person visit. It is often impossible to diagnose the problem based on an exchange over a crackly telephone line with patient who may not be able to hear or speak the language fluently. The patient may believe that a doctor who they know has been paid for the service will satisfy them with a script, certificate or referral in the way that any other telephone service operates. However the model for Uber Eats or Amazon does not fit healthcare where the need for information exceeds just the name, address and date of birth.

Covid will change everything including the way we consult doctors however not all changes will be for the better and telehealth consults that nurture unrealistic expectations will do more harm than good. It is rarely possible to meet the needs of all patients who might possibly have a telephone call with a doctor. In a trial of telephone consults more than 60% of patients needed to be seen face to face. If then those patient are advised that they must be seen in person, notwithstanding Covid the reality that the doctor is unable to meet their expectations may become a source of dissatisfaction and stress for all concerned. The art of doctoring is primarily an in-person activity. Telephone consults are adding to the challenges in primary care at the most stressful time.

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The biggest challenge is sustainability

My interview with Marie DeLuca is here.

Also Andrew Goldstein was interviewed here.

Health advocacy is being formalized as a professional activity for physicians across North America, but the accommodation of this activity into conceptions of daily practice has been controversial and confusing. There appears to be a lack of clarity around what a physician should do as a health advocate and how this should manifest in daily practice. In this article, the authors explore how the medical community has characterized the health advocate role and the roots of the debates regarding its place within training and practice, using the example of the CanMEDS Health Advocate Role. They argue that the confusion might be a result of subsuming two distinct activities, agency and activism, under the rubric of health advocacy. They propose that these activities and their associated skills are sufficiently distinct as to merit separate discussions. Agency involves advancing the health of individual patients (“working the system”), and activism involves advancing the health of communities and populations (“changing the system”). The authors suggest that distinguishing between agency and activism within health advocacy provides opportunities to explore their distinct goals and skill sets in a manner that will advance the debate about health advocacy, a conversation that remains critically important to the medical profession.

Dobson et al

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It’s not the symptoms, it’s the context.

More on the Art of Doctoring in my conversation with the one and only Baktash Ahadi

Objective. People with RA have episodes of worsening disease activity (flares) that prompt them to seek clinical review or medication change. This study explored patients’ perspectives of flare that prompts them to seek medication review.

Methods. Fourteen focus groups across five countries comprised 67 RA patients. Transcripts were analysed by several researchers and a patient, using inductive thematic analysis.

Results. Patients use flare for five different scenarios, including flare that prompts medical help-seeking, where six themes were identified. In ‘Symptoms and early warnings’, pain is intense (wanting to die), constant and persistent and considered a key feature. Systemic features predominate, including fatigue, feeling generally ill (flu-like), physical and cognitive shut-down and social withdrawal. Warning signs (prodrome) comprise fatigue and flu-like symptoms. ‘Self-management of intensifying symptoms’ includes pacing, heat/cold, rest and increasing medication, often without medical advice. Patients ‘Define this as uncontrollable flare’ when clusters of unprovoked, persistent symptoms halt their ability to run daily life, until prompted into ‘Seeking help when symptoms can’t be contained’. Underpinning themes are ‘Individual context’ (e.g. different symptom clusters) and ‘Uncertainty’ (e.g. when to seek help). Patients report that the current patient global visual analogue scale (VAS) does not capture flare.

Conclusion. Patients use flare for multiple events and seek help for complex clusterings of intense, unprovoked symptoms that defy self-management, not necessarily captured in joint counts or global VAS. Flare terminology and definition have implications for clinical practice and trials, therefore further research should establish a professional/patient consensus.

Hewlett et al

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How can you add value as a family doctor?

Ninety percent of people will consult a family doctor in 2020. The graph on the left suggests why they will do so. A significant number will have minor self limiting illness, a larger proportion will have chronic/ long-term illness and most will attend for multiple reasons. The graph on right demonstrates that most people will have risk factors for long-term illness often more than one risk factor. To reduce the risk(s) they will need to change their lifestyle. The challenge in primary care is to add value by triggering/ prompting lifestyle change. That is a very specialist skill set. Mandates a new paradigm and or a new set of tools.

Photo by Lāsma Artmane on Unsplash