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The management phase of the consultation may immediately follow the information-gathering interview, or it may take place on review, after diagnostic tests or referral. It should be remembered that there are at least two people concerned in management: the doctor and the patient. Poor patient compliance with any proposed therapy can be a result of a poorly conducted management phase. It is necessary not only for the doctor to make statements concerning therapy and the reasons for the chosen therapy, but also for the information to be conveyed in a language appropriate to each patient’s understanding. Negotiate a management plan.
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Management includes immediate care, prevention and long-term care. Doctors generally tend to be authoritarian in their management proposals. Whole-person management, however, implies that the patient’s views are listened to, explanations are offered where necessary by the doctor, and an educative approach is adopted to encourage the patient to actively participate in management and preventive behaviour, where possible.
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The objectives of the management phase of the consultation are summarised in TABLE 3.3.
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The sequence of the management interview4
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The following, which represents an excellent teaching strategy, is a suggested 10-point plan or sequence for conducting a management interview. These guidelines will not always need to be applied in their entirety, and may need to be staged over a number of consultations. The use of this sequence should ensure identification of all the patient’s problems by the doctor (including fears, feelings and expectations), adequate patient understanding of his or her problems, an acceptable and appropriate treatment plan being defined for each problem, preventive opportunities being addressed, and the patient being satisfied with the consultation and being clear about follow-up arrangements.
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The sequence is as follows.
Tell the patient the diagnosis
Establish the patient’s knowledge of the diagnosis
Establish the patient’s attitude to the diagnosis and management
Educate the patient about diagnosis
Develop a management plan for the presenting problem
Develop precise instructions using three headings:
Immediate: always included, even if no action is proposed
Long term: for chronic, long-term or recurrent illnesses
Preventive: sometimes specific measures apply—often patient education is the method required
The patient should be encouraged at this stage to participate in decision making regarding management and to make a commitment to the plans.
Explore other preventive opportunities
Reinforce the information
Provide take-away information
Examples of this important strategy include patient instruction leaflets and resource contacts.
Evaluate the consultation
Arrange follow-up
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Good closure is an important strategy; ask ‘Has this visit helped you and your problems—is there anything more I can do?’
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A patient management strategy
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Brian McAvoy, writing in Fraser’s excellent book Clinical Method: A General Practice Approach, presents a helpful aide-mémoire in the approach to patient management:9
reassurance and/or explanation
advice
prescription
referral
investigation
observation (follow-up)
prevention
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It is worth emphasising that prescribing medicine is a relatively complex skill that requires considerable knowledge of the disease, patient’s expectations, the drugs prescribed, their interactions and their adverse reactions. Part of this skill is making a decision not to prescribe medication when it is not absolutely necessary and then explaining the reasons and including non-pharmacological measures. This decision may be made in the context of a patient expecting a biochemical solution for his or her problem. As McAvoy points out, ‘If in doubt whether or not to give a drug—don’t’.9
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Rational prescribing applies particularly to opioids, antibiotics and tranquillisers.
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General guidelines for antibiotic prescribing
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Choose the agent with the:
narrowest spectrum that will cover the likely pathogens (based on culture/sensitivity)
lowest cost if efficacy and safety are otherwise equal
fewest serious side-effects
duration as short as possible
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Avoid wherever possible:
prescribing antibacterial antibiotics for viral respiratory infections
combinations if a single drug is likely to be effective
topical antibiotics, as resistance is much more likely to develop (exceptions include eye infections and vaginitis)
antibiotic combinations, except in proven clinical circumstances or when coverage is difficult with a single drug
prophylactic antibiotics, unless they are of proven benefit (in general only in some elective surgery or dental procedures)
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The common respiratory infections such as acute otitis media, pharyngitis, tonsillitis, acute bronchitis, bronchiolitis and influenza have commonly a viral cause and it is appropriate to treat symptomatically with a ‘wait and see’ surveillance.10
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The decision to refer a patient is also another important skill. It is often difficult to find the right balance. Some practitioners refer excessively—others cling to their patients inappropriately. It is a mistake not to refer a patient with a serious chronic or life-threatening disease. Apart from consultants and hospitals, referral should be considered to GP colleagues or partners with special interests or expertise, support groups and other members of the primary health care team, such as physiotherapists, dietitians, chiropodists and social workers. At all times the GP should act as the focal reference point and maintain control of patient management.
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The ‘gatekeeper’ role of the GP
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A patient’s GP is the obvious and ideal linchpin in the health care system to take responsibility for the patient’s health concerns and management. The patient may become confused with the system, especially if his or her problems are many and complex. The patient’s GP has a vital role in acting as a ‘gatekeeper’ between primary and secondary care, and between paramedical services. The GP should always act in the patient’s best interests and intervene, if necessary, to ensure that the patient is getting the best possible care.
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The healing art of the doctor
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The counselling process in general practice is based on the therapeutic effect of the doctor. This well-recorded feature is reinforced if the doctor has a certain professional charisma, and is caring and competent. We cannot underestimate the dependency of our patients on this healing factor, especially where significant psychic factors are involved.
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Key points on patient management11
It is difficult, perhaps impossible, to reassure patients in the absence of an appropriate physical examination and certain investigations.
Reassurance must always be appropriate and therefore based on a substantial foundation: inappropriate reassurance damages the credibility of both the doctor and his or her profession.
The two key characteristics of the doctor in establishing the basis of a successful outcome for the doctor–patient relationship are caring and responsibility.
Vital factors included in this relationship are good communication, genuine interest and trust.
Listen to what the patient is saying and not saying.