Being a GP, it's inevitable having friends approach me for a medical opinion. Recently a pregnant friend who typically has bad allergies was told in no uncertain terms by her GP not to take antihistamines because they are bad for the baby. Another part of the proposed solution was to get rid of their cat by asking someone to look after the poor fur ball until after she gives birth.
To no-one's surprise, the idea of cat abandonment was outright rejected. She did try to stop the unsafe antihistamines, but ended up taking some once or twice a week anyway because the symptoms were unbearable. Weeks later when the midwife told her that some antihistamines were actually suitable in pregnancy, my friend approach me about her situation.
Our beloved munchkin cat, Luna, in her days of kittenhood.
Paternalism: Here's What You Gotta Do
My goal here is not to judge the actions of another GP nor criticise their management of allergic rhinitis in pregnancy. I do however see a constructive learning point we can generalise from my friend's experience.
When GPs are under extreme time pressure, more often in bulk-billed settings, it is easy to see an issue (unsafe antihistamines in pregnancy), present a solution (avoid use of antihistamines and get rid of the cat) then send patients on their way leaving them the responsibility to comply. All doctors including myself have all been guilty of this at some point.
In fact, this actually happens all the time:
"Your cholesterol is very high, you are going to do some exercise and change your diet for the next six months. Then we will repeat the blood test."
"It's just a virus, so we shouldn't give antibiotics for your cold. Come back in a few days if you feel worse."
"Your back pain is just mechanical, which means it should get better within six weeks. Go to the physiotherapist, and if it doesn't get better by then, come back and we can do a scan."
All these scenarios are very reasonable, and the clinical advice may indeed be appropriate and evidence-based. The patient leaves with the impression that they should do what the doctor has told them.
So what are we missing here?
Compliance vs. Collaboration
Traditionally, whether patients follow through on what the doctor does is a matter of compliance, doing what they are told. Any disobedience means the patient is non-compliant, as though all fault lies with the patient in their lack of adhering to advice.
The more modern approach is a patient-centred collaboration which asks a few important questions:
What is the patient's understanding of the problem? How can doctors effectively convey information with clarity to help patients understand relevant issues?
How can patients be brought into decision-making about their health? What are critical pieces of information to help patients make such decisions?
What is the patient's view on proposed management options? What are some potential barriers or concerns and how can they be addressed?
How can the doctor work with the patient to implement the management plan in a manner that is relevant, practical and personalised for them?
My personal emphasis in the patient-centred approach.
Collaboration: A Patient-Centred Approach
For my friend, if removing the allergen (cat) wasn't an option and the severity of her condition was such that she cannot go without anti-histamines, the plan was doomed for failure from the start. It may have made a difference if there was an opportunity to discuss these potential barriers and negotiate a different individualised solution.
Likewise, for the scenarios listed above:
How long has the cholesterol been high and what measures have the patient tried in the past? Why have past measures failed? What are realistic goals the patient can suggest and agree to implement?
What is the patient's view on their cold? What were their concerns and expectations going into the consultation? If they are worried and wanting antibiotics, how can this be negotiated?
How does the back pain impact the patient's work? What are some potential psychological impacts from having back pain (such as being unable to pick up kids or do certain hobbies)? Perhaps a tighter follow up schedule is required to check in on the patient to provide further support and other management options as appropriate?
This approach translates to an often very time-consuming consultation. It is much easier and quicker to provide the correct solution and move on to the next patient. While cookie-cutter management may appear medically sound for the diagnosed condition, they may not be effective for the patient.
Exploring potential issues, discussing different viewpoints and options, then negotiating a plan can easily double the time of a consultation which most GPs do not have. Yet how effective we are as GPs are often determined by the extent by which we achieve collaboration, and ensure the patient is well understood through the discussion and implementation of a personalised management plan.
Why Blood Pressure?
I started my blog with simple articles on blood pressure. While the information is straight forward, my emphasis for patients to measure their own blood pressure is the very concept of collaboration.
Measuring blood pressure at home is never something I push onto patients, but I extend it as an opportunity to do something proactive about their cardiovascular health. It is a relatively easy task which patients cannot really fail, building their confidence. Finally, having a machine at home produces a sense of ownership about their health by providing the ability for opportunistic monitoring, improving health awareness.
In every consultation, GPs have a choice to promote cooperation and routinely bring patients into decision-making. Next time you go to the doctors, reflect on whether the plan is something you've been told to do, or if it's a personalised plan you have negotiated with your doctor which takes into account your concerns and needs. Every consult is an opportunity for you to take part in managing your health!
Broader Reading: Beyond the Basics
Patient-centred health is a broad topic, covered by numerous health bodies ranging from NSW Health to overseas institutions. This NHS booklet from the UK is an excellent read for patients to learn what constitutes patient-centred care.
Likewise, the Victorian government has a great summary on the key points of patient-centred care.
What does the patient-centred approach look like for children in the context of involving the family? The Sydney Children's Hospital Network provides an interesting overview of this.
Related to patient-centred care is the notion of patient engagement. The WHO has a document which provides insights for patient engagement in the primary care setting.
