PRIME INTERNATIONAL EMAIL - FEBRUARY 2022 - 'Knowing your Patient'
One of my most vivid recollections as a Medical Student was during a ward round on my first Surgical “firm” attachment. We approached a frail jaundiced man, keeping our distance at the end of the bed. The houseman’s voice, barely raised above a whisper, explained that a scan confirmed he had liver metastases from his bowel malignancy and there was little else to do. Then we all moved on without further engaging with him. I looked back and wondered what he must have felt. This brief experience was to colour my medical career. I came to appreciate that there was much more to medicine than diagnosis and treatment. If we connect with the patient, there is always some way we can help, whatever the circumstances.
We have known from numerous studies for some time that understanding your patient and practicing patient centered consultation is fundamental to providing good care and improving outcomes. One of my favorite quotes from William Osler is “It is much more important to know what sort of patient has a disease than what sort of disease a patient has”.
PRIME has included evidence to this effect in much of our teaching. However, a study 1 published in the 'British Journal Of General Practice' last November, produced dramatic evidence of just how important this is. This Norwegian study involved 4.5 million patients and their General Practitioners. The study examined outcomes during 2018 according to the length of time their doctor (defined as registration with the same doctor but effectively including consultations by all health practitioners in their practice) had known them from 1 to 15 years. The total population of Norway is only 5.3 million so almost all patients were included. (1)
Continuity in general practice as predictor of mortality, acute hospitalisation, and use of out-of-hours care: a registry-based observational study in Norway.Br J Gen Pract 2021
Of note here is that this continuity of care benefited the medical system as much as the patient. A 25% reduction in acute care would produce a massive improvement in the overall quality of almost any medical system. Even 10% (after one year’s patient contact) would be significant.
Furthermore, if I had discovered a treatment that reduced mortality by 25% it would no doubt be global news, but this seems to have received little attention outside the medical fraternity (it was the most read article in the BJGP last year).
Interestingly, average life expectancy in the UK was actually dropping before Covid, which begs the question is this in part caused by the poorer continuity of care we have seen over the last decade or so.
No doubt there were several other factors in play that contributed to these results, but surely the major one was the health practitioner’s ability over time to appreciate their patients' story, fears, health beliefs, and hidden secrets, which result in a more connected and trusting relationship.
Now, I can hear you all thinking, how do I have time to get to know my patient like this and surely I will never be involved with their care for 15 years in this era of fractured communication and super-specialism. Isn’t continuity of care inevitably a thing of the past?
Well, the study did not explore the Doctor or Practice variation in outcomes over time, but it would be interesting to know. My guess is that it could have been considerable. Jesus did not take long to make a deeper connection with those he met, so do we need years to do so? Sometimes just a few minutes listening to a patient will enable them to share something fundamental to their condition. So where do we stand now? On first impressions it would seem that this pandemic has done much to disrupt health provision, including continuity of care.
Worth reading however is Santhosh Mathew’s recent ICMDA Blog (2) entitled “Facing The New Normal”. Here he explores the effect Covid has had on us all and starts to unpack some of the potential benefits that we should grasp as Healthcare Practitioners. But, much depends on our ability to change, change the way we think, change the way we practice and change the way we work together. You may feel like a small cog on a large wheel but I believe we can all contribute to molding the system we work in.
Big change is often the sum of little changes. So, starting with ourselves and looking to our workplace, let us grasp every opportunity to make that smallest change that would contribute to continuity and patient centered care. It may be a simple word of encouragement to a colleague, the suggestion of a change in policy or how we use IT, or perhaps arranging a teaching opportunity that includes PRIME principles such as Compassion Without Burnout. Surely then together we could maximize the gain for our patients and indeed ourselves through these difficult times.
Dr Robert Sadler - Chair of PRIME Management Team
References:-
(1) From: Sandvik H, Hetlevik Ø, Blinkenberg J and and Hunskaar S. Continuity in general practice as predictor of mortality, acute hospitalisation, and use of out-of-hours care: a registry-based observational study in Norway.Br J Gen Pract 2021; DOI: https://bjgp.org/content/72/715/e84
(2) Facing the new Normal. https://blogs.icmda.net/2022/02/11/facing-the-new-normal/
