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The waiting game

Let’s start the new decade by telling patients the truth

Dr Shaba Nabi

The winter vomiting bug has done its rounds in our household and my daughter was the last to succumb. As I prompted her to drink more, she asked me which was healthier – water or milk? I thought about it for a few minutes and then told her it depends what you want to achieve. If you want to be hydrated, then water is healthier, but if you want calories and protein, then milk is healthier. She immediately declared she was dehydrated and went off to fetch herself a cup of water.

This simple conversation made me reflect on the outcomes we focus on in healthcare. It seems obvious to want to offer patients what they wish to achieve, but there is evidence of a mismatch between what they want and what is genuinely of benefit.

When patients were asked about the benefits of PCI in stable coronary heart disease, the overwhelming majority believed it would prevent recurrent cardiac events and reduce mortality, rather than the reality that it reduces angina.

There are many examples of patients overestimating the impact of medical interventions, the most significant being CPR. We are legally and morally obliged to practise person-centred care, but this includes informing patients of the risks and benefits of all options. Patients are seduced by the success of the sanitised version of CPR they see on TV, rather than understanding the horrors of broken ribs and vomit. No one is spelling out the reality – that when you’re frail, or comorbid, or have advanced cancer, your heart and lungs fail as a result of everything else failing, not as a primary event. In other words, it is time to allow you to die.

We need to stop asking ‘What is the matter with you?’ and start asking ‘What matters TO you?’

So, why are patients choosing interventions they may not fully understand or endorse? Much of this relates to the illusion of shared decision making; that if we hand out a patient leaflet, our job is done. But this half-hearted attempt at offering choice is actually worse than our historic paternalistic practice of ‘doctor knows best’. Offering interventions without adequate counselling and guidance can lead to choices patients may later regret (the case for some 20% of respondents in our recent CCG survey of 1,000 people)

So, as the NHS enters another decade, it’s time for a realistic conversation with the public about what it can and can’t achieve.

Admitting frail, care home patients who are in their final stages of life is rarely in their best interests. Adding yet another drug for someone with Type 2 diabetes is futile if they are still mainlining sugar. And trawling for people with ‘pre-diagnoses’ will just turn more of us into patients, with no evidence of benefit.

These conversations have already started with Scotland’s Realistic Medicine movement. Like any movement, it has to be underpinned by a change in culture that permeates every conversation up to the highest levels.

But our most important conversation is the one we have with a patient. We need to stop asking ‘What is the matter with you?’ and start asking ‘What matters TO you?’

After all, hydration mattered to my daughter, so I didn’t force feed her milk.

Dr Shaba Nabi is a GP trainer in Bristol. Read more Dr Nabi’s blogs at pulsetoday.co.uk/nabi

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Readers' comments (9)

  • David Banner

    The problem is that there are light years between what is promised to British punters against what is actually available.
    Patients are constantly fed a diet of early presentation, screening, self diagnosis, “see your GP if...” etc, then are disappointed and angry when confronted by the reality check of the “no appointments” delapidation of Primary Care in 2020.
    We all need to adapt expectation management strategies this decade. Learning to say “no” to patients is a tough gig, but if our paymasters continue to peddle “Paradise for all” in a parallel universe that no GP recognises, we need to be the harbingers of hard truths and harsher realities.

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  • Agree

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  • Spot on David

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  • What about having trust and faith in your doctor who used to look after you from the cradle to the grave... the doctor patient relationship seems to have been discredited by dr google and the politicians who promise all things to all people and then move on to their next career moves while doctors and patients relive Groundhog Day

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  • My personal list of worthwhile 'preventative medicine'
    Not smoking - saves the individual money, unquestionable benefit, no need for me to intervene to 'monitor '
    Childhood immunisation - some cost, but relatively fixed, no maintenance costs, benefits mostly not in doubt - read history books for justification, some negative pr from some groups, but mostly supported by the public.
    Exercise - benefits don't seem to be in doubt, motivating people seems to be a problem . The fact that there is no direct government intervention suggests that it is not cost effective, so it is left to us to 'encourage'.
    Addiction avoidance - self evident, and not just opiates and other recreational drugs and alcohol, but also gambling and obesity - the harm associated with these activities is huge and very costly, and not getting in to that state in the first place is clearly desirable, but does anything work?
    Things NOT on the list
    Treating and managing mild to moderate hypertension - the NNTs alone are pretty unimpressive, before you add the drug and management costs, side effects, and huge anxiety generated in patients for what in the end is just a small risk factor.
    Primary prevention treatment in hyperlipidaemia - see above.
    Chasing 95% of patients on the asthma register for annual checkups. They don't come because they feel well, or they can't be bothered. Yes we probably pick up a tiny few whose control could be improved, but is it cost effective?
    Pre-diabetes - we know that a large percentage of fat people become diabetic, and we know that to qualify as a type 2 diabetic you have to exceed certain diagnostic criteria. We now have to give special attention to those people near but not over the threshold, on whom we can devote time we cannot spare to encouraging them to mend their ways before it is too late, despite our relative lack of success of motivating the established type 2 diabetics. I'm not pretending that special attention will not work with some people, but again, is it cost effective? How many of the dozens of other things that people want us to do are we prevented from doing because of the priority given to preventative medicine at all costs?

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  • Where's Optimus?

    Golden minute at start then doctoring takes over
    I want to know symptoms and signs
    then i shall prioritise
    1. urgent
    2. none urgent
    3. other niceties of ice
    if time allows

    As we all know
    patients may present a list and
    what matters to them may be the most minor issue.. leaving the pr bleeding "by the way" as they are at the door about to leave

    p.s D+V some might say avoid dairy 24 hrs
    so no milk
    ? probiotic drinks

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  • Ooh probiotic drinks, they sound lovely, can I get a prescription.....

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  • diluted apple juice

    https://jamanetwork.com/journals/jama/fullarticle/2518402

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  • proper lemonade
    (it approximates to water/sugar/salt as in rehydration salts, if you allow nibbles of digetsive bicsuits!)
    (but proper lemonade is no longer available, only water laced with non-calorific 'sweeteners' which make it unpalatable)...

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