Treatment - Patient Management

Treatment

Differential Diagnosis

·        Always consider:

o   Autoimmune

o   Degenerative

o   Drugs

o   Doctors

o   Hereditary/congenital

o   Infective

o   Inflammatory

o   Idiopathic

o   Mechanical

o   Metabolic

o   Nutritional

o   Neoplastic

o   Pregnancy

o   Psychiatric

o   Trauma

o   Vascular

Formulating a case

·        Differential diagnosis

·        What are the risk factors

·        Problem list

·        Complications of problems and risk factors

·        Prognosis: how does this impact on treatment decisions

·        Investigations

·        Treatment + management/monitoring of side effects

·        Integration: stand back and think – am I missing something

Treatment Checklist

·        Listen (therapeutic relationship)

·        Education

·        Lifestyle (diet, exercise, etc)

·        Environment/social change

·        Psychological

·        Drugs

·        Surgery

·        Referral: to specialists, other health providers, support groups

·        Family involvement

·        Prevention

·        Public Health measures

Behavioural Change

·        Health Education is an attempt to achieve behavioural change

Parent and Adolescent Education:

·         Aim is to change behaviour.  Changing behaviour requires:

o   Knowledge: necessary but not sufficient

o   Skills: to manage the change

o   Motivation: Involves striving towards a goal, not just „trying‟.  The goal must be:

§  Important to the person – „I want this‟. Make it attractive. May need their goals to come before yours.

§  Achievable – „I can do this‟.  Believe in them

§  Not too unpleasant.  „I don‟t mind doing this‟.  Make it easy

·         Good counselling technique:

o   Open-ended questions: “tell me about….”

o   Active listening: “Hmm, I see…”

o   Reflection: reflect facts and emotions

o   Summarising: “Let me see if I‟ve got this straight….”

o   Don’t ask leading questions: eg “You don‟t do that, do you?”

·         Take a history using open-ended questions, reflecting, summarising:

o   Help parent or adolescent clarify exactly what it is they want to know

o   Knowledge: what do you understand about…? Where did you find that out? How convinced are you?

o   Attitudes/fears: are you worried about anything in particular?

o   Practices: What have you actually done so far?

o   Barriers: What‟s stopping you from doing this?

·         Then:

o   Validate/reinforce knowledge they already have: “That‟s terrific – you already understand a lot….”

o   Education to correct incorrect beliefs/address fears

o   Encourage them to find their own solutions: “So, what do you think you could do?”

o   Reinforce safe practices and responses

Stages of Change Model

·        Stages of changes (Prochaska and Di Clemente 1982): Discussion must be tailored to the stage they‟re at:

o  Pre-contemplation

o  Contemplation

o  Determination

o  Action

o  Maintenance (and maybe permanent exit)

o  Relapse (and maybe return to contemplation)

Readiness to Change/Motivational Interviewing

·        Motivation = the probability that a person will enter into, continue and adhere to a specific change strategy. It fluctuates. It is a state not a trait. Measure motivation by what they say not what they do 

·        Motivational interviewing: goal is to get from the patient their reasons for concern and their arguments for change. Especially helpful in precontemplation/contemplative stages 

·        Confrontation tends to evoke resistance.  Resistance ¯ the chance of change

·        Approaches at each stage:

o  Pre-contemplation:

§  Lack of knowledge or inertia

§  Rebellion: try to provide choices

§  Resignation: given up – try to instil hope/explore barriers

o  Contemplation:

§  Not equivalent to commitment

§  Extra information may not make any difference

§  Work through ambivalence, anticipate barriers, ¯ desirability of present behaviour

o  Dealing with ambivalence:

§  “Yes, but…” is normal

§  Helping people resolve ambivalence is key to change

§  Further education may result in conflict or denial

§  Try to get the patient unstuck

§  Poor self-esteem, social context and values may make this difficult

§  Highlight discrepancy between personal goals and behaviour. Best if they can identify this discrepancy themselves, rather than feeling pressured

·        Motivational Strategies (NB importance of empathy – understanding where the patient is at):

o   A – give Advice

o   B – remove Barriers

o   C – provide Choices

o   D – decrease Desirability: alter balance of perceived costs, barriers and rewards

o   E – practice Empathy.  Accept and understand without agreeing

o   F – provide Feedback

o   G – clarify Goals

o   H – active Helping

·        Counselling techniques:

o   Open ended questions

o   Reflective listening: voice what you think the patient means by what they are saying

o   Affirm: ­ self esteem and support the patient

o   Summarise

Brief Interventions in General Practice

·        Brief but repeated interventions avoid stigmatism, and are more effective than one long session

·        Direct advice normally provokes resistance

·        Opening lines:

o   “What are some good things about….  What are the less good things…”

o   Ask permission before giving information: “I wonder, would you be interested in knowing more

o   about ….”.  When you‟ve finished: “What do you make of all this?”

o   “What concerns do you have about …”

Breaking Bad News

·        Prepare patient for what is to come – give an honest explanation of why you‟re doing investigations before you do them 

·        Think ahead – invite family members when results come back

·        If there is no family, take a nurse (who has probably been preparing them anyway)

·        Ask patient what they understand is happening or what they‟re scared of – gives you a good intro

·        It is the patient‟s information – let them decide the pace and level of detail 

·        If the patient asks „have I got cancer‟ then they will have been thinking about it and will have a reason for asking – this is helpful 

·        If the patient asks „What do you think‟ then they‟re likely to be anxious. Need to open up discussion and give them opportunity to express their fears

·        Break up the information – „chunk and check‟.  Check understanding bit by bit

·        „Denial‟ can be shock, disbelief, or failure to understand. Denial is a longer-term pattern of behaviour. Whether denial is bad or not depends on the consequences

·        Document your discussion and what you‟ve said