A doctor ponders, a journalist reveals
BMJ 2003; 326 doi: https://doi.org/10.1136/bmj.326.7380.0/g (Published 11 January 2003) Cite this as: BMJ 2003;326:g
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EDITOR - Why don’t we use the simple concept of “aims” more in
medicine and in particular in General Practice ? As you write in your
Editor’s choice of 11th January, much of medicine is about treatment of
elderly patients and chronic disease. We also have a problem with patients
not returning for follow up of chronic disease [1].
When we feel frustrated in these circumstances it is often because we
don’t consider our aims and those of the patient rather than the shorter
term objectives. How often do we discuss aims with the patient and come
out with an agreed plan meeting common aims – a treatment contract ?
Recently a diabetic patient with high risk factors came to see me.
My objectives concerned his blood pressure, HbA1c and cholesterol. His
aims were to manage his injections and continue to work to support his
family. No wonder he misses appointments regularly. We struggle to keep
patients in their 90’s alive with ACE inhibitors when what they might
prefer is fewer side effects even with the possibility of a shorter life.
We spend hours analysing our consultations but rarely ask the patients
themselves afterwards if their aims have been met.
With chronic patients in particular we should consider asking : What are
the patient’s aims ? What are my aims ? What are our joint agreed aims ?
Then we might develop true partnerships with patients, realise our
limitations and feel that we are succeeding more often.
Catherine Elliott
GP trainer
West St Surgery, Chipping Norton, Oxon OX7 5AA
1 Lewis T, Woof R.Patient centred approach may help in hypertension
BMJ 2003; 326: 103. ( 11th Jan 2003)
Competing interests:
None declared
Editorial note
The patient whose case is described has given his signed informed consent to publication.
Competing interests: No competing interests
I think the term "bravery" as it is used in the article is kind of
vague, in that someone may be as "brave" to venture their first intimate
examination as someone else might be "brave" to express some moral stand
on probing someone under anaesthetic.
Of the hundreds of people that pass through the revolving doors of
hospitals, are there none who would consent to an intimate exam by a
prospective doctor? Has anyone ever tried getting consent?
Is date rape acceptable if the rapist stands to improve his techique?
Is a 28 year old patient to the medical profession what a 1998 Buick Regal
is to a mechanic? I don't feel that ethics and humanism are anathema to
the medical profession, although most health insurance providers here in
the US might argue with me.
Competing interests:
None declared
Competing interests: No competing interests
i have com across instances where doctors performed intimate
examinations when none were required. under anaesthesia, this opens
pandora's box for abuse. even if prior consent is obtained, examination
should be done in front of a senior person and a chaperon.also the
examination should be justified under anaesthesia.
other studies mentioned like coronary prevention came to nought. there is
some improvement using hip protectors etc. but the dominant question is
intimate examination. one has to justify it. mere consent is not a
licecnce,
manan vasenwala
Competing interests:
None declared
Competing interests: No competing interests
The fifth paragraph identifies the major problem which besets
healthcare provision in the developed world and the NHS in particular. I
would add that such practice yields minimal benefit to society at an ever
increasing cost which, I contend, is unsustainable. Surely it is high time
we stood back to allow a re-examination of priorities and the introduction
of fair and appropriate rationing based upon the 'fair innings' or similar
argument.
Competing interests:
None declared
Competing interests: No competing interests
Please,sir, what is a "CNS medical adviser"?
Competing interests:
I am of an age when my CNS is indrowing need of medical advice
Competing interests: No competing interests
I ask of you to please describe the hip protector
Competing interests:
None declared
Competing interests: No competing interests
Thank you for today's editorial. You have commented on a topic that
is a favorite of mine when teaching our Masters Degree students. The cost
of health care continues to increase rapidly in the US, now reaching
between 14 and 15% of the GNP. Most of this increase comes from treatment
of those over 50 years of age, and increasingly of those over 65 years of
age. Most of these conditions, for which we spend vast amounts of money,
often for relatively little benefit, are for conditions brought on by
individual behavior.
Obesity makes diabetes, arthritis, COPD and heart diseases worse. Lack of
exercise also affects the same conditions. Past and continued smoking
affect the heart, lungs and vascular system. Inappropriate diet has major
effects on the lipids.
Journalists, including medical ones, continue to extol unproven remedies
based on little or no research, much of which is targeted at the elderly.
It is time for a several BMJ issues to be focussed on geriatric medicine.
While the UK system has some limits built in, In the US the only limit is
the amount of money the public can coerce out the insurance systems and
the Government for wanted (not usually needed) interventions. Almost no
money (less than 2% of all medical outlay) is spent on prevention. If the
problems of the elderly are to get serious attention much more needs to be
done on the prevention (front-)end of the health system.
Competing interests:
None declared
Competing interests: No competing interests
Dear Sir
In the Editor's Choice of this weeks BMJ you remark that the mass
media will ignore many of the important studies in your journal to
concentrate on Peter Singer's study. This is perhaps not surprising given
that on the cover you have chosen to use a banner headline "Intimate
examinations by medical students" over a photograph of 3 rather sinister
looking masked "medical students". It strikes me that the doctor in the
BMJ editor has rather been overwhelmed by the sensational journalist in
him.
Yours sincerely
Simon Dando
Competing interests:
None declared
Competing interests: No competing interests
Re: The use of aims in General Practice - POM
Thoughtful and thought-provoking.
A generation ago Lawrence Weed (with his POMR) did the same but we
(doctors at large) laid the concept quietly to rest. We assumed that when
we see a patient we always listen to his problem and react to it. And that
we always search for the unspoken problem. Problem orientated medicine? It
is a bit more than "Complains of:"
Dr JK Anand
Retired
Competing interests:
None declared
Competing interests: No competing interests