The importance of listening and patient-centred care

5 June 2020 

Sylvia

As a new partner in 2007, I remember Sylvia (not her real name) well. She was a petite 83-year-old lady with a mischievous smile who lived alone in our local fold. "Not a pick on her," my grandfather would have said.

Her blood pressure had been difficult to control so with the arrogance of youth, I foolishly dismissed my colleague’s previous efforts and tried to manage it my own way, proudly displaying my newly learned skills.

I reviewed Sylvia regularly and each time it was the same story. Her blood pressure was not reducing and each time she had developed a new side effect to her medication. Sylvia had a "Very sensitive constitution" and was prone to diverticulitis, diarrhoea and abdominal pains.

This went on and off for the following year until I invited her into my surgery to discuss her care. She was on four different antihypertensives by this stage and she was not happy. Her blood pressure was still very high, and we discussed the benefits of treatment and why I felt it would benefit her.

To my surprise, and eternal shame, she paused and then started to cry. "I just hate coming into this building," she sobbed. "I like you, doctor Dorman, but I just feel so terrible on all these tablets."

I was stunned - and not a little embarrassed. We refocused our conversation and started to discuss things that mattered more to her. Her husband was an artist and had died seven years before.

She was very happy living in the local fold which was close to town and she enjoyed meeting friends and going to yoga. We talked some more about her tablets and their potential benefits. "What if I didn’t take them, doctor?" was her reasonable query. I had to admit I didn’t know, so we agreed to remove one tablet and review again in two weeks.

She proceeded to attend fortnightly reviews and a pattern emerged. She declined to have her blood pressure checked and after discussing carefully at each visit she stopped one blood pressure tablet.

This continued until all her antihypertensives were stopped. After one month off all medication the glint in her eye returned. She felt brilliant and was delighted to be able to go back to yoga.

I hadn’t seen her for some months and she unexpectedly returned to my surgery. It was good to see her again and she still refused to have her BP checked or consider any medication.

Yoga had been going well and she was meeting so many old friends for coffee, she felt she was starting to gain a bit of weight. I’ll never forget her standing up from her chair and wondered if she was developing "a bit of a muffin top!"

Sylvia lived until she was 89 and in these later years, had a very active and fulfilled life. I frequently think about her and how I hadn’t initially listened to her wishes and instead followed my own agenda about medications and how to treat her blood pressure.

I wondered if there was another tablet or combination I could have tried, or a better way to help her.

Hypertension

The latest 2020 Hypertension Guidelines from the International Society of Hypertension are helpful (Note: other guidelines are available) and have a section to address "adherence to treatment" in 8.3. They "helpfully" point out that nonadherence affects between 10% to 80% of patients!

I dislike the term “non-adherence” and prefer the term "concordance" which we can only achieve if we fully engage with our patients and make them feel part of the decision-making process.

Sylvia was fully engaged, was aware of the potential risks and had full capacity so was able to decide her own management. Strictly adhering to the tablets might have increased her life span by a few years, but at a considerable personal cost to her. 

It has been great to link in with some colleagues this week and share some best practice.

In Southern Trust we have a COVID Centre WhatsApp group where almost 180 GPs are all able to share latest guidelines, practice and operational issues.

An old friend of mine, Dr Orla Fitzsimons from Stewartstown Health Centre has shared a great app with the group called Here2Help.

It is available as a download from the app store and contains lots of helpful resources for patients who are suffering from mental health or other issues and is well worth checking out.

COVID's impact on vulnerable patients

I am always struck by how COVID-19 affects certain groups of individuals in different ways.

Deaf patients working in our health service have encountered difficulties lip reading when colleagues are wearing masks and RNIB have worked with Department of Health (DOH) and Department for Communities to help develop guidance which is worth checking out. 

On Wednesday, I had a very constructive meeting with Veronica Holland from the Department of Justice and Lisa Trueman from DOH about the proposed new Domestic Abuse Bill, which would make coercive controlling behaviour a criminal offence.

We were able to highlight that GPs and our teams have a massive role to play in the reporting of domestic violence and abuse.

Domestic violence always affects children who are cohabiting, even if they do not witness specific violent acts, and we have highlighted the need for good GP education.

There are two pilots in Northern Ireland using Identification and Referral to Improve Safety (IRIS) and I hope to link in with them soon to share their learning.

In the meantime, the IRISi website is available for all and has some helpful links, and of course there are also local links on the Here2Help app.

Sylvia’s story has resonated with me recently.

While I can accept I will never know absolutely everything about hypertension, the fact that she felt I hadn’t heard her did strike a chord.

I am working hard and genuinely want to do the best for you my colleagues, and to help ensure our patients receive the best care.

It is not easy, and I remember former RCGP Chair Professor Helen Stokes-Lampard telling me that it is like walking a tightrope while wearing high heels. While I do not have the same penchant for high heels as Helen does, I can appreciate her analogy. 

#RCGPLIVE

I want to hear more from you and what your challenges are now. What your fears and hopes are for the future, and how we can improve our patients’ experience of healthcare?

To start this conversation, I co-chaired the #RCGPLIVE webinar on Thursday night with Vice Chair Dr Gary Howsam, Welsh Chair Dr Peter Saul, Dr Mohan Sekeram, one of the regional leads for Person Centred Care, and Professor Josep M Vilaseca from Spain, who is treasurer of WONCA Europe.



It was great to hear these different perspectives and to share our own experiences from Northern Ireland.

My own practice in Kilkeel is restarting some chronic disease management. Instead of reviewing our patients from A-Z, we have started to look at the ones most at risk.

How are you managing chronic diseases? Please let us know so we can share best practice.

It was great to receive some questions from NI GPs on the night and I will take further a query we received about Vision practices not having access to Accuryx.

Unfortunately, we ran out of time to answer one NI GP’s question about Access Anywhere video consultations, so if you posed, this please contact me at the address below and I will get back to you personally.

We carried out a survey of GPs and their technological experiences during COVID-19 in April and we know there are issues that need addressed.

Technology was flagged in our vision report Support Sustain Renew as a key enabler and we have lobbied for a more focused approach to GP IT needs with HSCB and others.

Virtual roadshow

To help me hear your voices better we have arranged a virtual roadshow next week. On Tuesday, Wednesday and Thursday (9-11 June), I’m inviting you to have your voices heard.

The events are informal and will last no longer than 45 minutes.

The Zoom sessions:

Access links and passwords were sent to you via email this week (3 June). I am only sorry I cannot get out to meet you in your practices in person, but we must make do with the resources we have.

Please come along and help guide me.

We received the not unexpected news this week that our planned family holiday in France has been cancelled.

Despite this, I intend to take a week’s annual leave on 6 July, and I encourage all of you to ensure you take some holidays.

We all need to rest and charge our batteries so start thinking about what a staycation could look like.

In the meantime, I will need a volunteer to write this blog! If you have an interesting view of general practice or would like to host it for a week, please let me know.

Commitment to our values

Finally, a quick word about politics. RCGP is a non-political organisation but it takes its commitments to equality, diversity and inclusion very seriously.

It is hard for anybody not to have feelings stimulated by the turbulence in America this week and we hope all these issues can be resolved peacefully and quickly. 

In the meantime, we reach out to all our GPs from black and minority ethnic backgrounds. We thank you for your commitment to our communities and caring for our families. We are proud to be your colleagues.

I look forward to meeting as many as possible of you next week and hearing your views.

Email: ChairNI@rcgp.org.uk
Twitter: @laurence903


Post written by

Dr Laurence Dorman, Chair of RCGP Northern Ireland

Dr Laurence Dorman took office in November 2019 after three years as Deputy Chair of Policy for RCGPNI. A GP principal in Mourne Family Surgery, Kilkeel, Co Down, since 2007, he is the fourth generation of GPs in his family. He was also, until recently, the Chair of Newry and District GP Federation. 

Laurence has particular interests in new ways of working in primary care, cancer care, and inspiring the next generation of GPs. He set up the successful 'Dear Colleague' initiative to improve the interface between primary and secondary care and has been a strategic advocate for interface and communication since September 2017.

During his time as Chair, he wants to support College members to ensure that the future of GP services is protected, supported and sustainable.

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