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Gold, incentives and meh

Is patient with well-controlled diseases abusing your appointments system?

Three GPs share their approach to a practice problem

Three GPs share their approach to a practice problem

Case history

Mrs Smith suffers from diabetes, hyperlipidaemia and hypertension; these are all well-controlled and monitored regularly by you and the practice nurse. But Mrs Smith consults frequently in addition to her chronic disease monitoring appointments. She always brings several complex symptoms relating to at least three different systems but has difficulty both in getting to and sticking to the point.

She is keen to tell you her interpretation of her symptoms and usually manages to blame at least one of her various medications. As a result her consultations tend to take 20 minutes rather than the allotted 10.

Dr Elizabeth Scott

'Is she attending because of genuine side-effects or am I missing depression?'

Poor old Mrs Smith! I have been paying no attention to her cry for help and she is getting desperate. I have to make a clear decision whether she is continuing to attend because she genuinely has side-effects that make her life miserable, or that I am missing something like a depressive psychosis that will become embarrassingly florid in the near future. Or is she just using me as a lucky charm which, if touched often enough, will keep her safe?

Whatever my conclusion, it is clear that her anxiety levels are very high and that unless I do something, she will start attending with symptoms that do not relate to her current controlled conditions. I shall then be forced into expensive and unnecessary tests, so it is high time to address her problems. Almost certainly she resents and is afraid of her diabetes.

Will she die early with a huge ulcer on her foot like her grannie? She probably goes to bed worried about her hypertension and hypercholesterolaemia. Will her arteries silt up and force her into an ER scenario with rushing paramedics and defibrillators? Will her hypertension go ballistic and leave her paralysed and unable to complain any more?

I can't totally reassure her about any of these, but I can put her in touch with local diabetes clubs, hypertension care organisations, anti-cholesterol-help-yourself groups, yoga sessions, swimming clubs, or any suitable association that is local and sympathetic, where she can meet a group of like-minded people and let it all hang out.

She will learn all about herbal teas, vegetable diet recipes, diabetic exchanges that make sense, and will be able to transfer her dependence to her peers rather than to me, her doctor, whose surgery is as usual running late. Local health authorities publish lists of these associations but if there are none, it is time my practice started one.

Elizabeth Scott is a GP in private practice, interested in problems of sleep – she also serves on disability tribunals

Dr Alison Lennox

'I would let her speak for several minutes so she runs out of steam'

Mrs Smith sounds like a very familiar type of patient to me. It is always disappointing when organising patients into regular, efficient, disease-led monitoring clinics doesn't reduce consultation rates.

Mrs Smith's diabetes, hyperlipidaemia and hypertension would all be dealt with in a single nurse-run clinic on a fairly infrequent basis. This will probably seem very inadequate to Mrs Smith as she knows that she has three major conditions.

Mrs Smith craves attention. She needs you to know how special she is and that the various medications prescribed might be all right for ordinary people but not for her. Being categorised did not suit her at all. My tactics are to go with the flow, have a patient-centred consultation. I would let her speak uninterrupted for several minutes, while I listen very carefully to her complaints and theories. Most people run out of steam more quickly if you don't interrupt.

Then work out a management plan with her. Make sure she understands that you have considered her peculiar circumstances and that you fully realise she is not like anyone else. She needs to know you have appreciated how informed she is and that you have paid attention to her worries and observations about her treatment. This method should allow you to structure future consultations. It also gives her responsibility for her treatment and choices over various perceived or indeed actual side-effects. Once she is confident she has your full attention the consultations should go a lot better as she will not feel anxious or aggressive towards you, and generally this saves a lot of time.

Alison Lennox is currently working as a GP locum in Staffordshire

Dr Richard Stokell

'Her complaining behaviour may delay diagnosing the serious problem she will get in the end'

My first question is who has the problem. Clearly I have a problem because I am finding this patient frustrating and time-consuming. She is also a problem to our service because her excessive use is impairing access for other patients and making me run late.

But her behaviour may also be putting her own health at risk because a constant smokescreen of trivia is likely to delay diagnosing the serious problem she will inevitably get in the end.

My first task is to be as efficient as possible in the consultations. I would listen to the stream, say as little as possible and rely on this approach to obtain the whole list of symptoms. If I wait a bit longer she will probably start to prioritise them and only then will I be able to summarise them and ask her to focus on which are most important to her.

If she starts going on too much at this stage I would throw up my hands theatrically and say 'Stop! I can't possibly cope with so many different things at the same time'.

My next task is to try to get her to take responsibility for all the decisions. For her chronic conditions, I would consciously avoid checking blood pressure, assessing diabetic control and reviewing lipids. Instead I would advise her that our nurse is better at managing these problems in a planned way and I don't want to interfere with her care.

However, it is likely that early follow-up will be needed to look again at her 'list'. I would suggest perhaps two weeks later to maintain the progress made in this consultation. At that stage, I would present the list to her and ask for a progress report. I would hope to change her consulting behaviour gradually in this way.

Richard Stokell is a GP in Birkenhead – he is a trainer and course organiser

Learning checklist

What is good control in diabetes, hypertension and hyperlipidaemia?

  • Targets and evidence for national service frameworks, QOF and/or Joint British Societies (not identical)
  • Blood pressure
  • Lipid profile
  • HbA1c
  • Microalbuminuria
  • Use of appropriate medication

What are the advantages of structured versus opportunistic chronic disease management?

  • Can be delegated to appropriately skilled team members, freeing up doctor time and reducing costs
  • Ensures appropriate time allotted with right person
  • Can be scheduled to allow for staff holidays, etc
  • Signals importance of care programme to patient
  • Promotes adherence to agreed protocols – monitoring tests, changing management, provision of correct patient information, etc
  • Prevents wasted appointments by ensuring correct information is available
  • Discourages patients from raising other problems, reducing time pressures
  • Patients are less likely to slip through the net with implications for their own care and practice performance ratings
  • May be easier to audit

And the disadvantages?

  • Fragmentation of care may reduce patient and doctor satisfaction
  • Reduces patient choice – rigid appointment arrangements may not suit all patients
  • May become a tick-box exercise rather than a proper consultation
  • Health professional who does not know the patient may not be trusted as readily so that additional useful information is not given/elicited, or compliance is compromised
  • Discourages patients from raising potentially serious/urgent problems, or generates another unnecessary appointment (experienced GPs who know their patients can often safely and concisely deal with several problems in a single appointment)
  • Doctor-dependent patients may subvert system by making additional and unnecessary appointment

How should we counsel patients about side-effects and risks?

What are the ethical and practical issues raised if we:

  • Discuss all potential side-effects, quote the evidence-base and numbers-needed to-treat, then tell patients it's their choice
  • Warn only about serious side-effects
  • Advise patients to read the product insert advice
  • Mention no specific side-effects but advise patients to report any concerns

What skills may be useful in dealing with Mrs Smith?

  • Encourage her to bring a list so that it can be prioritised and an agenda agreed at the start of the consultation
  • Be firm throughout about the need to maximise the amount of time available; suggest follow-up or double appointment (but only if justified)
  • Summarise, and deliberately signal empathy; patients often persevere when they feel the doctor hasn't yet understood

Melanie Wynne-Jones is a GP in Marple, Cheshire

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