Month: October 2017

Posted in Consultation skills, Depression, Diagnosis, Mental health

Consultation skills – Tackling low mood and depression

Posted on by Emma

One of the commonest consultations we have in primary care is for low mood and depression. It’s also picked up during consultations where a patient may not have come specifically regarding their mood. As such it’s really important that we have the skills required to tackle this type of consultation.

With experience each of you will develop your own way of working your way through this type of consultation, and setting up your own schedule for reviewing, and providing ongoing care to this cohort of patients. But in the early days of training it can be helpful to hear about how others undertake such consultations, and shape this to fit your own style.

So I will talk through how I approach this type of consultation. I’m not planning to cover all the detail regarding diagnosing depression, and specific management protocols. You can find the most recent NICE guidance on the recognition and management of depression here

NICE uses the DSM-IV criteria for diagnosis of depression. It’s important to know this since this is how you are going to diagnose someone with depression, and recognise the different grades of depression from ‘sub-threshold’ to severe. By understanding the diagnostic criteria you will a) know what you need to ask your patient and b) be able to ascertain what type of treatment you may wish to offer to your patient.

DSM-IV criteria for major depression:

5 or more symptoms

  • Depressed mood for more than 2 weeks
  • Anhedonia
  • Poor appetite/ Weight loss > 5%
  • Insomnia/ Hypersomnia
  • Agitation / Psychomotor retardation
  • Reduced Libido
  • Loss of energy
  • Poor concentration
  • Thoughts of life not worth living / Suicidal ideation

Categorisation of depression:

  • Sub-threshold = < 5 of the above symptoms
  • Mild = only 5 (or not many more) of the above symptoms, resulting in only minor functional impairment
  • Moderate = Symptoms or functional impairment is between mild and severe
  • Severe = Most symptoms, and they have left a major functional impairment.

With the above knowledge we should be able to come up with a diagnosis, and a severity, of depression. However, the important part is how to gather that information. Sure, we could go through each of these symptoms very robotically, but is the person sat in front of us going to open up and be honest if you are undertaking a tick-box exercise? The answer is no!

It is this type of consultation where I find that a golden minute, or possibly two, is the most useful of any type of consultation. Because in that time you can get an idea of what’s going on, to what extent, and you get to look for all the verbal, and non-verbal cues, that will help you interpret what they are saying, and give you ideas of further questions you need to ask. I’m not going to teach you to undertake a mental state examination (I found a really nice summary here if you need to brush up on your skills), but during this opening minute or two you can start to cover some of the areas of the mental state examination. This is really important for considering the impact of symptoms upon the persons level of functioning.

I like to try and gather information regarding their other symptoms by turning the consultation into more of a ‘chat’ than an ‘interview’. I find this makes it more personal, and tends to develop a greater rapport with the patient.

In my head I am trying to be as nosy as possible, and painting a picture of this person’s life. By doing this I can work out what’s going on, why they might be in this position and the amount of support they have. In turn, this is going to help me offer them the best options for management.

What do I tend to ask about?

  • One of the big questions I ask is what triggered them to come and see me today in particular – this gives a really useful insight in to their situation.
  • I want to know when they last remember being themselves/happy/’normal’
  • Have they ever felt like this before? If so what happened at that time
  • Can they put a finger on what triggered this episode? Is that ‘something’ still happening?
  • Whats their home set up like – Who do they live with? Do they have children? Is home happy or are there stresses? Are their financial or marital concerns?
  • What do they do for work? How is their mood impacting upon work, and how does work impact upon their mood? Have they had any time off recently? If so, did things improve?
  • What makes them happy normally – Do they have any interests? Do they get time for themselves? Are they still enjoying those things they used to?
  • How is their sleep? If they are not sleeping well is it because they struggle to get to sleep, or are they waking. If they struggle to get to sleep – why? What are they thinking/worrying about?
  • Are they eating? Do they enjoy mealtimes as before?
  • Do they smoke, drink, take drugs?
  • Who is in their support network locally – do they have one? Have they got family and good friends locally? Have they talked to any of these people about how they are feeling? Is there any history in the family of low mood/depression/other psychiatric illness?
  • Have they got to the point where they’ve felt so low that they have thought about harming themselves in any way? Or thought about ending their own life? If they answer yes to these questions then I am going to ask for more information (I will chat about this more below)
  • In anticipation of this appointment, have they thought about what might help them get better? Are there any specific treatments they wanted to talk about? What are their views on taking tablets? Have they taken any medications for mood in the past, or undergone any psychological therapies?

By the end of this questioning I feel like I have a really good grip of whats going on, what it might be sensible to offer, and what my follow up plan will be.

If they answered yes to the question regarding self harm and/or suicidal ideation then I need to talk about this in a bit more depth. I acknowledge that this might be difficult for them to talk about, but that it’s important for them to be as open as they can so that I can help to the best of my ability.

If they express that they have thought about taking their life I ask about what those thoughts have involved? How often they’ve occurred? Do they have any intention of acting upon them? What would stop them from doing so? Have they ever had thoughts like this in the past and have they ever attempted suicide in the past?

Asking these questions allows me to generate a degree of risk. Again, this will alter my management plan. Someone who has clear plans, and no clear support or inhibitive factors is going to make me question whether I ought to make a same day referral to the crisis team. Those with thoughts but no active intention I am going to follow up sooner than those with no thoughts of self harm. At this point I also take into account the demographics of the person sat before me. Male suicides are more common than female, and middle-aged males more likely to commit suicide than anyone else.

Only you can decide what your follow-up consultation interval will be for each patient. You are making your own risk assessment, and often this is affected by our personal level of risk. For me, it might be between 2 days to 4 weeks. I might even follow someone up by telephone the following day if I’m particularly worried, but I don’t feel there’s anything specific that warrants a crisis team referral. Bear in mind that some crisis team referrals are bounced back pretty quickly so even if you do refer, you need to continue with your own follow up plans.

What are the management options?

This will be tailored to the patient in front of you but can range from no treatment if they have sub-threshold depression, or there’s a specific incident driving their mood that they just need to be supported through. It may require low intensity psychological therapies such as self guided or computerised CBT, or medications.

Medication ought to be reserved for those with moderate or severe depression, or where they have a past history of moderate or severe depression. It may be considered if they have had sub-clinical or mild depression that has persisted for a couple of years, or where low intensity psychological therapy has failed.

It is important to consider patients ideas and choice. However, I often make it clear that medication may help the symptoms, but if there is a clear trigger then it is most helpful to address this. Hence why psychological therapies can be very useful. Sometimes it’s the conversation you have that breaks down their barriers and opens them up to trying such therapies. If they are not keen initially I will ask them to think about it and discuss it more next time.

LOCAL TO PETERBOROUGH

  1. Patients can self – refer for psychological therapies. In those who I  feel a re low risk with sub-clinical and mild depression I advocate this. It gives the patient some ownership of their symptoms, and there is less likely to be a non-adherence to treatment if they have chosen to refer themselves.
  2. We have 111 option 2. By calling 111 and selection option 2 they are put through to a first responder from the mental health trust. They are trained to talk to patients over the phone, with the aim of avoiding A+E attendances. They are also working with Mind (a mental health charity) to provide ‘safe havens’ where people can go out of hours if they are experiencing a crisis.

Please feel free to use the comments section to share your ideas, or ask questions related to the above. Also, would it be helpful for me to post a video of a simulated consultation for this topic?

Posted in Book review, Palliative care, Uncategorized

Book recommendation – Being Mortal by Atul Gawande

Posted on by Emma

This post is not going to teach you anything – it’s a book recommendation. I know you might be thinking ‘when do I have time to read a (non textbook) book?’ but stick with me.

I came to read this book, not through selecting it myself but it was gifted to myself, along with a copy for all the doctors in our practice, by a patient. So, I added it to my growing pile of books to read. I tend to save books for holidays because I am an avid reader – one that struggles to read just a few pages at a time. But I knew I would read it. If someone has taken the time to gift you a book then it’s got to be worth a read.

I wasn’t entirely sure what the book would cover, since I hadn’t read the Amazon synopsis in advance. So to convince you it’s worth your time I will give you a rough idea, and place it into the context of why it was a great read for me.

The book covers the issue of death, and how we get there. Atul Gawande is a surgeon in the USA, and he wrote this book after reflecting on his experience of caring for older people – professionally and personally, and looking after those with terminal diagnoses. It is a personal reflection of his journey to improving the care of those people in the later stages of their life, and in the terminal phase. He looks at ageing (briefly), and how that impacts upon physical ability. Then puts this into the context of care of older people – in hospital and beyond. He looks at how modern medicine impacts upon mortality, and the choices available to people of all ages when they are given an end of life diagnosis. Finally, then looking at the change from managing at home to needing nursing home care, and how this has changed with time. He has spoken to palliative care specialists, those who have worked within the social care setting, colleagues, and most importantly patients.

All of the above is why I urge you to read this. How many of you have spent much time in your medical education and work, to date, dealing with end of life care directly? I recall my time as a trainee in the hospital recognising that people were moving into the terminal phase of my life, but not having the seniority to ‘make the call’. Sometimes I’d be given the responsibility of having discussions with relatives, to pass on the decisions made by senior colleagues. Sometimes I would watch as colleagues made seemingly unfathomable decisions that we must continue aggressive treatment of patients. I actually found some of my hospital shifts extremely upsetting as a result of this. I felt helpless watching management plans unfold, and being complicit in seemingly irrational management plans. The hospital is a busy place, and often understaffed at weekends. This could lead to a more senior doctor not having time to review your patient, and thus see in reality their situation. As such this sometimes seemed to prompt them to make management plans that would serve as a ‘holding plan’ until they could get to see the patient. My issue with this process was that by undertaking and ABG, or a portable CXR, you are suggesting to the family members who are watching their relative get sicker, that there is a way back from this. Yes, sometimes this is the case, but in one particular experience (I recall the scenario vividly – it happened 7 years ago) I knew that they would make no difference, but I followed orders. I remember thinking at the time I would rather spend my time talking to the family, and making this death something they wouldn’t remember as traumatic in any way. I didn’t get to do that. I felt really unsatisfied with my job when I got home that day.

This book, didn’t solve anything for me, but it made me think of how it could help hospital colleagues. It made me consider how I could potentially help my patients avoid being in this position when they reach the hospital. It opened up the idea of very frank and honest discussions. I thought I was trying to do that already, but this book gave me some tips on how to refine this.

It didn’t take too long to read. I also found there was no part of the book that I felt the urge to skim read. It was all interesting, and pertinent to the role of a GP. I encourage you to read this book, because I think it will improve your care of those patients reaching the later phase of their life, and making that time a positive experience for themselves and their family.

You can find a link to the authors website, and more information on the book here

 

Posted in ARCP, eportfolio, ESR, MRCGP

Reflective learning

Posted on by Emma

This entry has come about through a chat with one of our trainee’s. He felt that it was difficult to get to grips with reflection. He told me that he got to know about Gibbs (1988) reflective cycle, and that this had improved his ability to reflect. I also recalled this was the model my sister was encouraged to use during her midwifery degree.

So I went back to my theory from my Postgraduate Certificate of Medical Education, did a bit more reading, and thought I’d share the salient features. Having looked through numerous theories of learning and reflection I do agree that Gibbs’ method fits the GP e-portfolio learning log well.

It’s important to note that reflection is a very personal experience. It can give an insight to your personality, and can reveal how you are feeling at a point in time. It’s useful to be open when writing a reflection, and feeling comfortable that whoever reads your entries will treat this information as confidential, and be supportive and developmental in their feedback. Though, it is sometimes easy to fall into doing a lot of description, and sharing of feelings, but less about how this has impacted upon your learning, and any changes you might make. Hence, why having some models to frame your reflection upon can help.

One of the earliest theorists to consider reflective learning was Dewey. His thoughts were that reflection was potentially very useful when making sense of situations that we may have found difficult. To learn from it required a description of the event and questioning ourselves to analyse why it occurred in that way, and considering ways to change the outcome of the event. (Dewey, 1933)

One of the most common theorists to come up in discussion of reflection is Kolb. His learning cycle (1984):Kolb learning cycle

It’s a very simple model. But what I don’t like about it is that one of the stages is to ‘reflect’ and I find that it doesn’t help with structuring the reflection. Instead, I would use this model in association with another model, that discusses the reflection in greater depth.

So we come to Gibbs Reflective cycle (1988).

Gibbs reflective cycle

Gibbs’ model of learning is what we call iterative – learning through repetition. The aims of his model are to:

  • Challenge assumptions
  • Explore different ways of doing things
  • Promote self-improvement
  • Link practice with theory
  • Thinking about the positive as well as the negative

I’m going to give an example of a reflection using this structure

Description – I saw a man in his 30’s who presented with haematospermia. It had happened on 2 occasions. As soon as he told me what the problem was I realised I knew nothing about the topic.

Feelings – I felt myself getting stressed because I didn’t know what I was going to do. I really had no idea whether this was something to be concerned about or not. I think, looking back, I must have looked disinterested because my mind was wandering trying to think what I was going to do, whilst he was still telling me about the problem.

Evaluation – Actually, I don’t know if he noticed just how stressed I was, as I managed to keep calm on the outside which was good. I explained a need to check some guidelines so I could quickly look on GP notebook to work out what to do! He seemed satisfied with the consultation, though I was quite worried that I’d missed something else during the time I wasn’t fully listening.

Analysis – I think my worry that I knew absolutely nothing about the topic hindered my ability to listen to the patient, and thus my consultation skills were not up to scratch. If I had been able to keep calm, and think ‘I can look this up’ earlier on, it would have facilitated a better consultation.

Conclusion – I could have been completely open with the man and said I wasn’t sure and needed to have a look/ask a colleague. I could have done this during the consultation or afterwards and followed this up with a call. I also think that I need to separate my concern about a lack of knowledge from the consultation structure. It hampered the consultation, and added extra stress.

Action plan – I will read up on haematospermia more thoroughly, and this might lead on to other men’s health topics I have less knowledge about. I will also try and role play some consultations where I really don’t know the answer, and try to focus on what I can do. I can also try out different ways to signpost that I need to look up some information.

References:

  • Dewey, J. (1933) How We Think. A restatement of the relation of reflective thinking to the educative process (Revised edn.), Boston: D. C. Heath.
  • Kolb, D. A. (1984). Experiential learning: Experience as the source of learning and development (Vol. 1). Englewood Cliffs, NJ: Prentice-Hall.
  • Gibbs G (1988) Learning by Doing: A guide to teaching and learning methods. Further Education Unit. Oxford Polytechnic: Oxford.
Posted in Cardiovascular system, Chronic disease management, Consultation skills, Diagnosis, Hypertension, Uncategorized

Hypertension – the diagnosis

Posted on by Emma

I’m covering this as it’s a common reason for consulting in primary care. What do you do when you pick up a high blood pressure as part of an examination for another presenting complaint? The answer should not be ‘ignore it and hope it goes away’!

As always, you can read the NICE guidance for all the ins and outs of hypertension diagnosis and management. What I’m going to do is give you some tips on what might be helpful during a consultation where someone has a raised blood pressure but no diagnosis of hypertension.

What I will say (and I can imagine this will become a familiar phrase) is that it is not easy to complete all of this in one 10 minute consultation. So it’s worth planning how to tackle this over a couple of consultations.

Most importantly, you need to know what raised blood pressure is. Here are the definitions to guide you:

  • Stage 1 Hypertension – clinic BP 140/90mmHg or higher AND subsequent 24h BP or home monitoring BP 135/85mmHg or higher
  • Stage 2 Hypertension – clinic BP 160/100mmHg or higher AND subsequent 24h BP or home monitoring BP 150/95mmHg or higher
  • Severe Hypertension – clinic systolic BP 180mmHg or higher OR clinic diastolic BP 110mmHg or higher

I think it’s fair to consider their reason for attendance, and whether this may be impacting upon their BP reading. The other important point is that your patient should be relaxed and quiet whilst the measurement is being taken. It’s a good time for you to complete your documentation. It can be hard to convince a patient to sit and say nothing! Also – make sure you’re using the correct cuff size – this really does impact upon the measurement.

If the BP is high on the first reading then measure it on the other arm also. You should have at least two measurements of BP if the initial one is >140/90. You may take a third if there is a significant difference between the first two. Document the lowest reading taken.

Your first consultation is likely to go as follows if you note a raised BP:

  • You will need to organise 24 hour (ambulatory – ABPM) BP monitoring OR home BP monitoring (HBPM). You might want to discuss these options with your patient. The ideal is ABPM.
  • You can also introduce the idea of hypertension and the lifestyle factors that might impact upon the patient’s BP. It gives them a bit of information to digest in the meantime, and it may allow them to consider how they can alter their lifestyle to make improvements.
  • You can also organise further investigations required to assess for target organ damage (kidneys, heart, eyes), and perform a cardiovascular risk assessment:
    • Bloods – renal function, lipids, HbA1c, liver function (if considering statin)
    • ECG – look for LVH, and REALLY helpful to have a baseline ECG
    • Urine – for albumin: creatinine ratio
    • Fundoscopy – you can look yourself but signposting them to an optician for a detailed check is helpful.
  • To complete a CVD risk assessment (a Q-risk in our case) we will need some information regarding family history of CVD, their height and weight (to calculate BMI), their smoking status, and checking their pulse for AF (which should ideally have been done prior to BP measurement since it can affect electronic BP recording)

You can see that after you’ve taken a history and reached the point of diagnosing a raised blood pressure (which may not have been their reason for attendance) there is quite a lot of explanation and planning to get on with! Don’t forget to address their actual reason for attendance if it wasn’t related to blood pressure.

NOTE – If you diagnose someone with severe hypertension, you need to consider starting an anti-hypertensive there and then. You should probably get on and get some bloods taken on the day to facilitate appropriate monitoring of the medications you have started (e.g. unless you have a recent renal function it is good to get one taken prior to starting an ACE inhibitor, since we need to monitor renal function after initiating said medication). You must also consider referral for same day specialist input if they have signs of papilloedema and/or retinal haemorrhage, or if they have symptoms to suggest an underlying cause e.g. phaeochromocytoma, or referral for investigation if this is possibly secondary hypertension.

The follow-up consultation is hopefully going to be straightforward if you have completed all of the above.

You are going to have the BP monitoring results and be able to diagnose hypertension, and which stage. You will also have the investigation results. This, in turn, allows you to manage the condition appropriately.

What are the lifestyle measures patients’ can take to reduce blood pressure? Did they have a think about these after the last consultation? Are there any changes they think they can realistically make?

  • Diet and exercise (including reducing salt intake, and reducing caffeine intake)
  • Quitting smoking
  • Reducing alcohol intake
  • Relaxation therapies

Who are we giving drug treatment to?

  • Stage 1 hypertension and < 80 years old with:
    • target organ damage
    • established CVD
    • 10-year CVD risk > 20%
    • Diabetes
    • Renal impairment
  • All stage 2 hypertension

Consider referral if < 40 years old with stage 1 hypertension and nil other risk factors, since CVD risk may be underestimated in this population. We need to be looking for a secondary cause in these individuals and offering detailed assessment.

Hypertension should be monitored through clinic readings (unless they have white coat hypertension, in which case home monitoring can be used).

Target BP in clinic is <140/90 if <80 years old or <150/90 if 80 year or older. (home monitoring is <135/85 for < 80years and <145/85 if 80 years or older).

I’m going to stop here.

Do you know which antihypertensives should be used in which groups?

Do you know the stepwise treatment for hypertension?

Do you know how different drugs should be monitored, and what common side effects you might experience with the different medications?

Please use the comments section to try answering some of these questions, or if you have any questions regarding what has been discussed above!