How was your weekend? Maybe like me on sunday afternoon you found yourself in a glorious alternative reality, as the match commentator stated that it was 5-0 to England. At half time. It doesn’t get much better than that! My weekend had started less positively, as I found myself getting up (a little resentfully, if I’m honest) earlier than desired to go into work and do a three hour surgery. I decided that for both my patients and I to get the most out of the surgery, I would make a note of how many of the consultations were rooted in wellbeing and lifestyle issues, and to dig a little deeper with those patients to help them get the most out of the consultation. After all, if I’m going to blog about wellbeing I need to make sure I’m practising what I preach, not just summarising the theory. The results genuinely blew me away…so today’s blog contains the summarised highlights and learning points of my experience. In case you’re worried about GDPR (that’s General Data Protection Regulations to those of you fortunate enough not to have to know this), there is no patient identifiable data contained in this blog. For those of you desperately disappointed that this isn’t the Weekly Wellbeing Round #3, I promise that it will be back next week!
So what did I learn?
- There’s a lot of it about. Two third of the consultations were primarily about an underlying wellbeing or lifestyle issue. I was expecting it to be high, but not that high! Of those two thirds it was about a fifty fifty split between those that openly acknowledged this was the problem and those that either weren’t aware of it, or chose not to acknowledge it.
- It’s easy to take the path of least resistance with a prescription and do your patient a disservice. At least two of the patients that I saw presented with one simple symptom, for which they were asking for a quick fix, usually a prescription. One patient had a rash. They just wanted some cream for it, having tried nothing at all so far. I could have just prescribed steroids. I’ll be honest – depending on how late I’m running and what sort of day I’m having, I have historically taken the easy way out, gained myself five minutes of catch up time and breathed a sigh of relief. However, the reason they had this rash was because of chronically swollen and inflamed legs, which in turn was due to their weight. I did give them some cream, but only after we had spoken about their weight, what they felt about it, what they had previously tried in terms of weight loss etc. They left not just with their prescription but with a weight management referral. I could have spent time talking to them about a low carb diet but they gave me the very clear steer that they really wanted to be told what to eat and to be held accountable and would prefer a weight management programme.
- Social history is important, particularly occupation. Doctors are taught to take a social history. This is particularly pertinent in primary care. However, as the years have gone by and the time pressures have increased, I find myself sometimes taking shortcuts. That may well be okay in the case of minor illness and discussing blood results, but it’s an important part of the picture as a determinant of wellbeing. Of the cases that I identified as related to wellbeing and lifestyle, half were at least partly occupation related. They were either the primary cause of stress and multiple symptoms, or contributing significantly to the problems. I may not be a career advisor, but what’s the point of repeatedly consulting for mental health issues, signing prescriptions and sick notes to address the symptoms, without challenging a person to consider addressing the cause?
- Ideas, concerns and expectations. Oh how we love them. Anyone who is a GP reading this will be familiar with these terms. They are all about the importance of establishing a patient’s understanding, their fears and what they want to get out of the consultation. Having been a GP for almost eighteen years now, I sometimes end up feeling that all a lot of patients want is a referral for a fancy test or to see a specialist who will fix the problem that I can’t (or that they don’t believe I can). What was really interesting about my wellbeing surgery experience was that my assumptions were often incorrrect. When we began to explore the issues and the options for dealing with them, a significant number of the patients did not want a blood test, or a drug, or a referral. They were actually very happy with advice about lifestyle medicine and even expressed relief that it was something they could be in control of.
- It’s okay to be honest and you don’t have to “fix it”. The consultation that I found the most challenging was with a patient who was actually very up front about the reasons for their wellbeing concerns and clearly identified work and relationship issues that were causing them a lot of stress. They had adopted some unhealthy coping mechanisms as a result and , in my opinion, their situation was clearly unsustainable in the long term without serious consequences for their health. The problem for me was that they made it very clear they weren’t immediately planning on taking personal responsibility for the situation and making any of the vital changes that they needed to improve things. They also made it very clear that that felt it was up to me to sort them out, and requested various medications to this end. When I was younger and less experienced, I would have felt pressured into prescribing because it was the only thing that I could do. It would have also made the consultation much shorter. Now that I recognise this is actually not serving the patient well at all, I pushed back and (having checked they were safe from a mental health perspective) challenged them about expecting medical solutions to a problem that they should be dealing with themselves. We agreed to a further consultation to discuss this some more and I also gave them our wellbeing team phone number so they have someone else to talk things through with.
- Wellbeing and lifestyle medicine is increasingly on the patient agenda. A lot of patients are very well informed, even if they don’t have my obsessional podcast/blog reading habit. Wellbeing is increasingly on the political agenda and in the media. Some of the patients who identified lifestyle issues were already well on the way and we talked about a number of concepts and resources such as Public Health England’s Active Ten campaign and app, Dr Rangan Chatterjee’s excellent 4 Pillar plan, the concepts of a low (or low-ish!) carb diet, time restricted eating and weight management programs. It’s very rewarding to see people making changes and just to touch base with them occasionally or give them a gentle nudge here and there as they work their way through managing their own wellbeing.
- It does take a bit longer. Case selection is key! My clinic did finish on time, thanks to the one third of people who came with minor and easily addressible problems. I’m not going to lie to you…to do this properly does take a little longer. My belief is that if health professionals invest just a little extra time with the right people, the benefits in the long term will be significant. A very small proportion of people genuinely have no insight and are not willing to take any responsibility for their own wellbeing and may not respond to this approach. However, if a doctor would offer a double appointment to a patient with serious mental illness, a complex long term condition or a newly diagnosed cancer, why would we not do the same for someone who could make huge, lifelong gains in wellbeing as a result of a little extra time? A GP can sometimes feel a bit of a lightweight if they book too many extra long appointments. Patients may feel they are taking up too much of the doctor’s time with “minor” issues. I would argue that of all the things we spend more time on, this is one of the most potentially beneficial areas for patients and health professionals alike.
I hope that you have found my sharing this helpful, whether you are a patient or a health professional. Weekly Wellbeing Round Up service resumes next week
Until next week, look after yourself!
Dr Richard Pile