Everyday Consultations Research Articles

Implementing an Innovative Lipid Management Technique Using siRNA LDL-C Lowering Therapy: Lessons Learned in an NHS Primary Care Practice With Worked Case Examples.

The UK Government partnered with industry to tackle cardiovascular disease (CVD) in the first NHS population health agreement. The ambition was to prevent 150 000 strokes, heart attacks and dementia cases over the next 10 years with a new siRNA LDL-C lowering therapy (Inclisiran) delivered within Integrated Care Services by primary care to support a comprehensive approach to lipid management. Following the approval of inclisiran, and guidance published by the National Institute for Health & Care Excellence (NICE) on its use, this paper has been created by a UK general practice to share real-world observations of cases and the potential service benefits of rolling out this innovative drug treatment. The process of identifying patients at risk of atherosclerotic cardiovascular disease (ASCVD) and lessons learned from implementing in practice is also addressed. Workstreams were developed to rapidly roll out a low clinical burden enhanced lipid management program incorporating siRNA LDL-C lowering therapy into primary care practice. (1) Multi-disciplinary team (MDT) education program based on freely available Academic Health Science Network (AHSN), National Institute for Health & Care Excellence (NICE), and commercial materials. (2) Automated searches using a software program were run to identify "at-risk" patients alongside manual case-finding in everyday clinics. (3) Patients were invited for review using multi-channel modalities. (4) Where appropriate, treatment was commenced after consent was obtained. (5) Automated recall systems are used to ensure follow-up; initially at 3 months, then every 6 months. Enhanced lipid management as a secondary prevention measure is achievable in line with national guidance and objectives. The methodology and education/training processes used in combination with reconstructing the management process can help practice staff realize the program benefits, which in turn can lead to a shift in behavior where all staff embed manual case-finding of high-risk patients into everyday consultations and reviews; enabling rapid identification of eligible patients. Taking a multi-disciplinary, holistic approach to new initiatives reduces service burden, particularly for GPs. Leveraging resources from the AHSN and others removes additional training pressures often associated with new initiatives and provides a wealth of educational material to support primary care MDT upskilling.

Changes in Clinical Practice amongst Nepalese Otolaryngologists during COVID-19 Pandemic

Background COVID-19 pandemic changed clinical practices more so for otolaryngologists due to inevitable risk of exposure.
 Objective To assess the changes in the clinical practice among Nepalese otolaryngologists during this pandemic.
 Method It was an observational study conducted as an online survey in the first two weeks of December 2020. A questionnaire pertaining to changes in clinical practice was mailed to 190 registered otolaryngologists working in various provinces of Nepal. Data were entered in Microsoft Excel 2007 and analysed in percentages.
 Result Out of the 77 (40.5%) who responded, nearly 50% resumed clinical practice after a month of national lockdown restarting everyday consultation by 64.9% mostly in hospital setting (81.8%) after screening patients via fever clinic by 87%. Modifications in clinical examinations was mostly done for neck (85.7%), oral cavity (44.2%) and nose (29.8%) examination with least with for ear examination (3.9%) Regular endoscopic evaluation was avoided by 19.4%. Only around 57% used adequate personal protective equipment. There was 93.5% reduction in elective operations. Mandatory COVID test was done by 89.6% mostly with reverse transcriptase polymerase chain reaction (95.9%) prior to semi-urgent case.
 Conclusion Changes in clinical practice were adapted to mitigate viral transmission. The changes were evident in the outpatient department where most patients were screened for fever and modifications made in the clinical examinations. Personal protective equipments were worn when available. Operative lists were limited to semi-urgent and urgent cases with covid testing customarily done for semi-urgent cases.

Sexual history taking in primary care

Sexual history can be neglected in a routine nursing or medical assessment. Sarah Kipps gives tips to assist in making a sexual history taking session as comfortable as possible for both health professional and patient Practitioners in primary care are in a unique position to improve the sexual health of men and women. They can do this by introducing the topic of sexual health into their everyday consultations and thereby normalising the subject as part of routine health for the patient. There is evidence that health professionals find sexual history taking to be one of the more challenging aspects of a consultation. There are a number of different reasons for this: feeling not equipped to ask questions of such a sensitive nature; fear of opening a ‘can of worms’ which cannot be dealt with; and the general social embarrassment and difficulties experienced talking about sex in general. This article will give health professionals some tips and guides to assist in making a sexual history taking session as comfortable as possible for both health professional and patient.

Identifying the supportive care needs of men and women affected by chemotherapy-induced alopecia? A systematic review.

To systematically evaluate evidence regarding the unmet supportive care needs of men and women affected by chemotherapy-induced alopecia (CIA) to inform clinical practice guidelines. We performed a review of CINAHL, MEDLINE, PsychINFO, Scopus, the Cochrane Library (CCRT and CDSR) controlled trial databases and clinicaltrials.gov from January 1990 to June 2019 according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement. Twenty-seven publications were selected for inclusion in this analysis. Included reports used qualitative (ten) and quantitative (17) studies. Across these studies men and women reported the major impact that CIA had on their psychological well-being, quality of life and body image. Hair loss had a negative impact irrespective of gender, which resulted in feelings of vulnerability and visibility of being a "cancer patient". Men and women described negative feelings, often similar, related to CIA with a range of unmet supportive care needs. Some patients are not well-prepared for alopecia due to a lack of information and resources to reduce the psychological burden associated with CIA. Hair loss will affect each patient and their family differently, therefore, intervention and support must be tailored at an individual level of need to optimise psychological and physical well-being and recovery. People affected by CIA may experience a range of unmet supportive care needs, and oncology doctors and nurses are urged to use these findings in their everyday consultations to ensure effective, person-centred care and timely intervention to minimise the sequalae associated with CIA.

To what degree do patients actively choose their healthcare provider at the point of referral by their GP? A video observation study

BackgroundMany countries in Europe have implemented managed competition and patient choice during the last decade. With the introduction of managed competition, health insurers also became an important stakeholder. They purchase services on behalf of their customers and are allowed to contract healthcare providers selectively. It has, therefore, become increasingly important to take one’s insurance into account when choosing a provider. There is little evidence that patients make active choices in the way that policymakers assume they do. This research aims to investigate, firstly, the role of patients in choosing a healthcare provider at the point of referral, then the role of the GP and, finally, the influence of the health insurer/insurance policies within this process.MethodsWe videotaped a series of everyday consultations between Dutch GPs and their patients during 2015 and 2016. In 117 of these consultations, with 28 GPs, the patient was referred to another healthcare provider. These consultations were coded by three observers using an observation protocol which assessed the role of the patient, GP, and the influence of the health insurer during the referral.ResultsPatients were divided into three groups: patients with little or no input, patients with some input, and those with a lot of input. Just over half of the patients (56%) seemed to have some, or a lot of, input into the choice of a healthcare provider at the point of referral by their GP. In addition, in almost half of the consultations (47%), GPs inquired about their patients’ preferences regarding a healthcare provider. Topics regarding the health insurance or insurance policy of a patient were rarely (14%) discussed at the point of referral.ConclusionsJust over half of the patients appear to have some, or a lot of, input into their choice of a healthcare provider at the point of referral by their GP. However, the remainder of the patients had little or no input. If more patient choice continues to be an important aim for policy makers, patients should be encouraged to actively choose the healthcare provider who best fits their needs and preferences.

Broader concepts of quality-of-life measurement, encompassing validation - AY Finlay.

It is difficult to imagine nowadays not taking into account patients’ quality of life. This is largely thanks to Andrew Finlay for drawing out attention to the importance of measuring the burden of skin diseases. In describing in his article1 the journey leading to the development of the DLQI, he highlights the importance of listening to our patients and being good scientists. Because once clinical practice is transformed into science, it can never be suppressed. How many of our patients were suffering and being mistreated before this? How many were not helped in their lives, ravaged by a visible, painful or itchy disease? In how many cases were we unaware of the patients’ discomfort with the treatments we prescribed, in some cases with greasy creams or coloured lotions? The DLQI was wisely developed to adapt to our busy professional lives, as well as to be protected from bad translations, partial use and other misuses that gave it all its power. Andrew Finlay and his team have given a voice to all our patients in everyday consultation. This contributes to a new way of practicing medicine and dermatology, putting the patient in the centre, making a person-centred consultation.2 Moreover, this is also the best way to evaluate the efficacy of new therapies, as for example the biologic therapies that are now available. With the use of this tool, it becomes clear that some of our patients need this therapy, even if it is expensive.3 The DLQI gives a framework to use with the patients who are suffering the most. And the findings do not always coincide with what we think. It is clear now that psoriasis, for example, is a disease that can have a deep impact in the lives of the patients, both in the present and in the future. The burdens of this skin disease can sometime take patients to suicidal ideation.4 We are less likely to overlook those patients if we use the DLQI in routine practice. Andrew Finlay and his team were also the first to evaluate the family impact of childhood atopic dermatitis.5 By developing the Family DLQI, they gave us an easy tool to screen this dimension. And we need to help the parents to cope. For that purpose, atopy schools were created all over the world. Finally, this article opens the door to the strategy used to develop and to go further in this domain. This experience of 30 years is very precious to each of us to understand how to develop other practical tools that can make science help our patients.

Medically unexplained symptoms: the person, the symptoms and the dialogue

Many general practitioners (GPs) find the care for patients with medically unexplained symptoms (MUS) challenging. The patients themselves are often not satisfied with the care they receive. The aim of this study is to explore what patients with MUS expect from their GP by looking at relevant communication elements in consultations as identified by patients. We video-recorded everyday consultations with GPs and asked the GPs immediately after the consultation whether MUS were presented. The patients in these MUS consultations were asked to reflect on the consultation during a semi-structured interview while watching a recording of their own MUS consultation. The interviews were analysed qualitatively according to the principles of constant comparative analysis. Of the 393 video-recorded consultations, 43 concerned MUS. All MUS patients said that they wanted to be taken seriously. According to the patients, their feeling of being taken seriously is enhanced when the GP: (i) pays empathic attention to them as individuals, meaning that the GP knows their personal circumstances and has an open and empathic approach, (ii) ensures a good conversation by treating the patient as an equal partner and (iii) is attentive to their symptoms by exploring these symptoms in depth and by acting on them. Like chronic patients, patients with MUS value a personalised approach in which GPs pay attention to patients' personal circumstances, to proper somatic management of their symptoms and to a proper conversation in which they are treated as equal partners. Use of these basic consultation skills may greatly improve care of MUS patients.

More than clowning around

David Wheeler gives a GP’s view of clown improvisation workshops and tells how they have helped him to cope with the emotional workload of everyday consultations

Applying Motivational Interviewing to School-Based Consultation: A Commentary on “Has Consultation Achieved Its Primary Prevention Potential?,” an article by Joseph E. Zins

Despite a decade of advances since Zins' 1995 article on prevention, much work lies ahead to make prevention everyday consultation activities for school psychologists. To foster prevention efforts, this commentary discusses how motivational interviewing in school-based consultation (a) might peak consultees' initial interest in change, and (b) address barriers to successfully implementing and maintaining change plans.

‘Are My Bones Normal Doctor?’ the Role of Technology in Understanding and Communicating Health Risks for Midlife Women

Contemporary medical science is increasingly saturated with risk and uncertainty, uncertainty which health professionals are obliged to manage in everyday consultation situations, but which patients presenting with specific health problems, want resolution to. This paper provides an overview of literature concerning the medicalization of women's bodies via health interventions such as screening, including the role played by medical technologies in defining degrees and forms of risk and uncertainty which are embedded within and generated by the screening processes themselves. We draw upon an ESRC funded study into the use of health technologies in women's midlife, in order to demonstrate how empirical research can illuminate the links between screening for osteoporosis and the recommendation and subsequent decision by women to use therapies such as hormone replacement therapy (HRT). The paper explores the centrality of bone densitometry in decision-making about potential risk. Drawing mainly upon data from 24 consultations in specialist clinics, 10 follow up interviews with the women concerned and 7 interviews with linked health professionals, we focus upon the interpretation and significance of the bone scan results. We conclude that, although the technological results are open to flexible interpretation, they seem to confirm the ‘at risk’ status of many of the women. The scan results appear to assume centre-stage in the consultation discussions, leading both women and clinicians to over interpret their significance as an indicator of risk.

Relevance and practical use of the Consultation and Relational Empathy (CARE) Measure in general practice

The Consultation and Relational Empathy (CARE) Measure has been developed as a tool for assessing the patients' perceptions of relational empathy in the consultation. The present paper provides performance data on the CARE measure in a large sample of general practice consultations in areas of high and low deprivation. The CARE Measure was included in a self-completed questionnaire study involving 3044 patients attending 26 GPs in 26 different practices (16 in areas of high socio-economic deprivation and 10 in low deprivation areas, in the west of Scotland). GPs and patients, in both high and low deprivation settings, endorsed the relevance of the CARE Measure. Overall, 76% of patients rated the measure as being 'very important' to their current consultation. Higher rating of importance were observed in older patients, patients consulting with psycho-social problems, patients with long-standing illness or disability, and patients with significant emotional distress. Few patients rated individual CARE Measure items as being 'not applicable' to their current consultation; only 3.1% of patients felt that more than 2 of the 10 items in the measure did not apply to their current consultation. Mean values were not influenced by deprivation, gender, reason for consulting, chronic illness, or emotional distress. Correlational analysis indicated that a sample size of 50 patients is sufficient to reliably estimate mean CARE score for an individual GP. These results indicate that the CARE Measure is considered by GPs and patients alike as being of direct relevance to everyday consultations in general practice, in both high and low deprivation settings. The measures is stable across patient groups and a reliable estimate of perceived GP empathy requires 50 completed questionnaires per doctor.

Management of osteoporosis in general practice: a cross-sectional survey of primary care practitioners in Spain.

A cross-sectional survey was conducted to determine the current situation in Spain regarding diagnosis and care of patients with osteoporosis in the primary care setting. A total of 2,500 primary care physicians who were homogeneously grouped in autonomous communities throughout the country received a postal 30-item anonymous self-administered questionnaire. The questionnaire covered demographics and personal characteristics of the physicians, conditions in everyday consultation, and degree of knowledge with regard to risk factors, diagnosis, treatment, and follow-up of the disease. The overall response was 850 (34%). The mean age of physicians surveyed was 43 years (range 23-66 years). The percentage of physicians specialized in community and family medicine was 46.7%. In 55.2% of cases, years of practice ranged between 11 and 20, and 55.7% of physicians visited between 31 and 50 patients per day. Age and years of practice were not associated with daily number of visits. Only 4% of physicians stated that there were specific programs for osteoporosis implemented in their primary care center. Diagnostic complementary investigations that could be ordered included plain radiographs in 96.2% of cases and bone densitometry in 27.8%. Laboratory tests included serum hormones in 61.6% of cases, PTH in 50.2%, and bone alkaline phosphatase in 33.4%. The diagnosis of osteoporosis was made always personally in 25.2% of cases. Personal diagnosis and follow-up, as well as actions directed to detection of osteoporosis were significantly higher among physicians working in centers with specific programs for osteoporosis. With regard to knowledge about osteoporosis, the mean percentage of correct responses was 63%. The percentage of correct responses was inversely associated with age and years of practice, and positively associated with speciality of community and family medicine. Primary care providers are in a good position to assess risk factors and recommend prevention strategies, as well as to play an active role in the diagnosis, care, and follow-up of patients with osteoporosis. Practitioners of younger age and relatively few years of practice were those with more up-to-date information regarding the disease, and the existence of a specific program for osteoporosis seems to improve the management of this condition.