January 22, 2009

Patient Management in General Practice

Today we discussed the principles of patient management, which can be summarised into these 3 points:

1. Reaching a shared understanding of the problem with the patient
2. Negotiate the management plan
3. Give the patient the responsibility for the problem

These points should be worked through in order, and to achieve this we should use the RAPRIOP acronym: Reassurance & explanation, Advice, Prescription, Referral, Investigations, Observation, Prevention.

REACHING A SHARED UNDERSTANDING OF THE PROBLEM WITH THE PATIENT

There are two points here. The doctor must understand the problem from the patient’s perspective, and the patient must understand their problem from the doctor’s perspective.

In order for the doctor to manage the patient, they must fully understand the patient and how their problem affects them. To do this the doctor must elicit the patient’s ideas, concerns, and expectations, and make the ‘triple diagnosis’ (i.e. how does the problem affect the patient from a biological, social, and psychological perspective). This is done as a part of competent history taking.

Now the patient must also understand the doctor’s view of their illness, this is basically the medical side of things. Here the doctor must use reassurance and explanation to give the patient an understanding of their illness in their own terms. The doctor may discuss anatomy, pathophysiology, epidemiology etc etc, or none of this if the patient does not want to know!

NEGOTIATE THE MANAGEMENT PLAN & GIVE THE PATIENT RESPONSIBILITY FOR THE PROBLEM

I have chosen to discuss these points together as I feel that they are closely interlinked.

I think the key word here is negotiate. The management plan should be decided upon in a two-way process between the doctor and the patient. The doctor must tell the patient about their options for treatment, so this would usually involve either prescription or referral, or both. The doctor should tell the patient objectively what each prescribed treatment would involve, i.e. risks, side-effects. They must also endeavour to find what the patient wants from their treatment. The patient must be empowered and encouraged to decide upon a management plan which suits them best.

In this way the patient can be given responsibility for their problem, or at least offered the opportunity. Indeed, some patients would must prefer that the doctor makes all the decisions unilaterally, though I think this situation should be avoided and the doctor should make the utmost attempts to fully involve the patient in their own care.

Other aspects of the management plan which I have not yet discussed include: referral, investigations, observations, and prevention.

REFERRAL

This can mean referral to a specialist doctor, a senior colleague, or the consulter may refer to an information source to refresh their knowledge about the diagnosis in question. Referral is something which all doctors should be proficient in doing as it is a necessity when a medical problem demands skills or knowledge beyond the bounds of their own competence.

INVESTIGATIONS

These can be used not only to differentiate between working diagnoses, but to monitor a patient’s progress, and also to reassure an anxious patient. An investigation should not be performed however if it does not impact on the patient’s management plan or welfare.

OBSERVATION

In the general practise setting observation can mean to give a follow up plan, this can be an open follow up or a closed follow up.

Open follow up is where the consultation ends with the patient being informed on the prognosis of their condition and then advised about the conditions under which they should seek another consultation. Safety netting is an important tactic used here.

Closed follow-up is where another consultation is agreed in advance, i.e. “come back in 6 weeks and we can check your blood pressure to see if the medication is working”.

PREVENTION

Disease screening and address modifiable risk factors.


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