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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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COVID-19 will impact more than those with the virus

The December, 2019 coronavirus disease outbreak has seen many countries ask people who have potentially come into contact with the infection to isolate themselves at home or in a dedicated quarantine facility. Decisions on how to apply quarantine should be based on the best available evidence. We did a Review of the psychological impact of quarantine using three electronic databases. Of 3166 papers found, 24 are included in this Review. Most reviewed studies reported negative psychological effects including post-traumatic stress symptoms, confusion, and anger. Stressors included longer quarantine duration, infection fears, frustration, boredom, inadequate supplies, inadequate information, financial loss, and stigma. Some researchers have suggested long-lasting effects. In situations where quarantine is deemed necessary, officials should quarantine individuals for no longer than required, provide clear rationale for quarantine and information about protocols, and ensure sufficient supplies are provided. Appeals to altruism by reminding the public about the benefits of quarantine to wider society can be favourable.

Brookes et al The Lancet Volume 395, Issue 10227, 14–20 March 2020, Pages 912-920

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Your choices in medicine make the greatest difference

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Can doctors learn from movie directors?

In any consultation involving health professionals there are two ‘actors’ the patient and the health professional. During that meeting each will have something to say and will say it in a specific way. The tone, the emphasis and the volume of their speech will offer information. The actor’s limbs and torso will reflect their thoughts and feelings during the meeting. Their hand gestures and their head movements will betray emotion.

These aspects are not be formally taught at medical school or at least not in the way that actors are taught their craft. And yet how the doctor plays their role in the consult will impact the outcome of that meeting with the patient.

As doctors or health professionals we can’t anticipate how the ‘other’ actor in the meeting will choose to present themselves in the meeting but we can learn to become much more aware of our own behaviour. How we position ourselves, the movements of our limbs, our facial expression, our gestures, our non-verbal response to the information received from the other. In most meetings we have very little time to make an impact in the desired direction and a failure to become self aware will undermine our efforts to be of help.

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