Realistic medicine Flashcards
What are the core ideas of Realistic medicine (2015)?
> Build a personalised approach to care
> Change our style to shared decision-making
> Reduce unnecessary variation in practice and outcomes
> Reduce harm and waste
> Manage risk better
> Become improvers and innovators
Build a personalised approach to care - things to consider? (An otherwise healthy active middle aged man presents with incidental finding of hypertension and hypercholesteraemia, his dad died of a MI)
What information does he need?
Think of the Patient Centred Care – The Use of Data tutorial
How might you illustrate risk? Could you show him his risk reduction? - remember the Assign tool.
Think of Actual Risk Reduction and Relative Risk Reduction.
Would that help him to decide? What do you think his options are?
Where might he be on the Cycle of Change? (Realistic Medicine - Children’s Health and Health Promotion)
It’s not unusual for a clinical letter to state that a patient requires a drug.
Does he ‘require’ or ‘need’ treatment- what does the group think ‘NEED’ means in this context?
What is a citizens’ panel - What makes a good doctor??
1) Knowledge and qualifications
2) Good listener
3) Friendly and approachable
What is a citizens’ panel - what are the most important elements of a good consultation with a doctor?
1) Feel listened to and not rushed
2) Clear communication
3) Resolution/ diagnosis/ outcome
What is a citizens’ panel - how comfortable do you feel asking a doctor what are my treatment options?
92% feel comfortable
What is a citizens’ panel - how comfortable do you feel asking a doctor what are my treatment options?
92% feel comfortable
Although its the approach of the doctor that determines this. In practice only 67% actually ask due to this.
What is a citizens’ panel - how comfortable do you feel asking a doctor how likely are these to happen to me?
87% feel comfortable
The following guidelines regarding osteoarthritis?
For analgesia - Consider using oral paracetamol and topical NSAIDs prior to opioid analgesics
Where paracetamol or topical NSAIDs provide insufficient pain relief for people with osteoarthritis, then the addition of an oral NSAID/COX-2 inhibitor to paracetamol should be considered
The following guidelines regarding constipation?
For the management of short-duration constipation:
- Manage any underlying secondary cause of constipation, and advise the person to reduce or stop any drug treatment may be causing or contributing to symptoms, if possible and appropriate.
Possible secondary causes of constipation include:
> Drugs
- Aluminium-containing antacids; iron or calcium supplements.
- Analgesics, such as opiates and nonsteroidal anti-inflammatory drugs (NSAIDs)
- (and a long list of others)
The following guidelines regarding constipation?
For the management of short-duration constipation:
- Manage any underlying secondary cause of constipation, and advise the person to reduce or stop any drug treatment may be causing or contributing to symptoms, if possible and appropriate.
Possible secondary causes of constipation include:
> Drugs
- Aluminium-containing antacids; iron or calcium supplements.
- Analgesics, such as opiates and nonsteroidal anti-inflammatory drugs (NSAIDs)
- (and a long list of others)
The following guidelines regarding CKD
1.3.8 In people with CKD the chronic use of NSAIDs may be associated with progression and acute use is associated with a reversible decrease in GFR.
Exercise caution when treating people with CKD with NSAIDs over prolonged periods of time.
Monitor the effects on GFR, particularly in people with a low baseline GFR and/or in the presence of other risks for progression.
Fracture risk associated with the use of morphine and opiates?
An increased fracture risk is seen in users of morphine and opiates.
The reason for this may be related to the risk of falls due to central nervous system effects such as dizziness.
Mortality after total hip replacement surgery?
Total hip replacement causes a short-term increase in the risk of mortality
It is important to quantify this and to identify modifiable risk factors so that the risk of post-operative mortality can be minimised. When quantified it shows low incidence.
Reduce Harm and Waste
Jacob Bigelow “the amount of death and disease suffered by mankind would have been less if all disease were left to itself”
Often there is over diagnosis
Which conditions are most commonly over diagnosed?
- Prostate and thyroid cancers,
- Asthma
- Chronic kidney disease
- Attention deficit hyperactivity disorder
What are the risk associated with over diagnosis to an individual?
Overdiagnosis may be the norm rather than the exception. This matters because once people are labelled with a diagnosis, a cascade of medical, social, and economic consequences follows—some of which are permanent.
Abnormalities for on scan in asymptomatic people?
- Disk bulging
- Disk degeneration
- Partial R.C tear
- Bursal thickening
- CAM deformity
- Pincer deformity
- Labral injury
- OA
- Cartilage defect
- Meniscal tear
- Mortons neuroma
- ATFL
Essentially it is likely a pathology will be found if a scan is performed
What would happen it 100 people over 60 years of age took sleeping tablets form more than one week?
1) 7 people would get an extra 25 minutes of sleep.a night and eat up less.
2) 76 people see no difference
3) 17 people have side effects. One is likely to have a major accident or fall
What is the issue with stricter diagnosis criteria with hypertension?
13 million people now classed as hypertensive and require treatment which they did not before.
Drugs increased the risk of kidney injury (ACE-I and diuretics), or ankle swelling and flushing (CCB), bradycardia (Beta blockers) or lethargy or erectile dysfunction
Influences medical, holiday insurance and even your ability to gain a mortgage.
Increased worry can even increase the risk of a stroke
Remember managing risk is personal to each patient
For example you may treat an 8 year with iron deficiency different to a 79 year or even a pregnant women.
A middle aged man presenting with iron deficiency anaemia may even prompt a cancer screen which has its own risks.
Become improvers and innovators?
The emphasis on using data to support discussions and learning in clinical teams is already an established approach within general medical practice.
Surgeons may take surgical safety “pauses” to assess outcome nation wide and decrease mortality and morbidity.
It is essential to use an evidence based approach to improve services and treatment. Reflection is a key aspect of this
What five question should be asked to ensure you have all the information you need to make the right decisions about your care?
1) Is this test, treatment or procedure needed?
2) What are the potential benefits and risks?
3) What are the possible side effects?
4) Are there simpler, safer or alternative treatment options?
5) What would have if I did nothing?
This Course, in teaching you about management of Risk, Evidence Based Medicine, Patient Centred Care, Communication of Information and Shared Decision Making has hopefully prepared you to be ‘Realistic Doctors’
Looking back to the Citizens Panel report earlier, patients (people) desire a friendly, knowledgeable doctor who is able to communicate accurate information well and with whom they are comfortable sharing decision making.
