Appointment day—the tip of an iceberg
BMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k430 (Published 14 February 2018) Cite this as: BMJ 2018;360:k430
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Anya de Iongh describes what can happen when someone with long term conditions (LTCs) has an unsatisfactory annual visit to a clinic. While not universal some of the issues described are sadly recognisable. Care and support planning (CSP) using a Year of Care approach was developed to address these problems systematically.
The Year of Care CSP programme involves a change to the traditional annual review which, together with changes to processes, skills and attitudes, involves a ‘preparation’ step for the person and professional. This may include an initial information gathering appointment for those with tests and tasks to complete. Everyone receives an ‘agenda setting prompt’ alongside results and supporting information to help consider what’s most important to them one to two weeks before the consultation appointment itself. This also benefits the professional in helping understand what could really make a difference to the person and allows for the ‘professional story’ to be incorporated into the appointment appropriately.
Clips from people who have experienced Year of Care CSP address most of Anya’s issues and include a comment “it’s quite a pleasure to come now” (https://www.yearofcare.co.uk/what-others-have-said). Year of Care have a wealth of experience and resources to support primary care and specialist teams across the UK and beyond to implement a CSP approach with the aim of it becoming the norm for routine annual visits.
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In contrast to the choir of praise (mainly on Twitter), I would like physicians to say: We know this! We’re on it! We do x, y, z to respond to such concerns. For every time doctors are amazed that a patient is a feeling person who has a life before and after a consultation, I just want to weep with anger! Every time doctors discover that what they say can have impact on me and my emotions, I really think there is something seriously wrong with medicine.
Anya de Iongh's article is great, very powerful, very moving, but it shouldn't be needed in the first place! Sadly, the discoveries it offers to medicine suggest that it is.
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What a powerful article.
I note that the GP did not feature in the article. He or she could have been helpful, but we are rarely experts in the medical and practical aspects of living with chronic diseases, even the common ones.
The article underlined for me the importance of nurse specialists: professionals who know a lot about the problem, and are accessible and approachable, and also know the patient. They should be able to help with a lot of the questions that get knocked of the list of things to ask the consultant, and they could be very useful in helping prepare the patient (and with the patient’s permission, the consultant) for the consultation, and with the debriefing afterwards.
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Anya de Iongh's article was a welcome departure in the BMJ and one I understand will become the norm.
Whilst I appreciate the focus was on the consultant appointment, I found myself asking where the GP was in all this.
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Opening the conversation
This insightful patient perspective is welcome. But off course every patient is different. Some come with stable disease and wish to be discharged to the community. Some come having read of a new treatment and want to know more. Some come with a list of difficult ongoing or worsening physical symptoms. Some come with difficult emotions.
A clinician cannot always easily ascertain the patient's agenda. I have found a simple approach is to start the consultation with the question "How are you?". If patients are emotionally unwell, this gives them the opportunity to explain. If they say they are well, I then follow up with "And how are your ears?" (or whichever body system is under discussion). Once the physical and emotional symptoms are revealed, a plan can be made (or an acceptance that everything possible is being done),
At the end of the consultation, I close by asking the patient if there is anything else they want to discuss. If there are emotional issues they have not been able to or wanted to discuss earlier, they may volunteer this at this stage. I finish by asking the patient when they would like to be seen again (returning control to them). I suggest that they contact me if their symptoms are worse, or postpone follow up if all is well. Many patients with chronic disease want to be seen when emotional or physical symptoms are worse, and an annual appointment may not correspond to that.
I do not propose that this approach is a panacea, but I believe it is often effective.
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