Realistic medicine

Question 1

What are the core ideas of Realistic medicine (2015)?

Answer 1

> 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

Question 2

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)

Answer 2

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?

Question 3

What is a citizens’ panel - What makes a good doctor??

Answer 3

1) Knowledge and qualifications
2) Good listener
3) Friendly and approachable

Question 4

What is a citizens’ panel - what are the most important elements of a good consultation with a doctor?

Answer 4

1) Feel listened to and not rushed
2) Clear communication
3) Resolution/ diagnosis/ outcome

Question 5

What is a citizens’ panel - how comfortable do you feel asking a doctor what are my treatment options?

Answer 5

92% feel comfortable

Question 6

What is a citizens’ panel - how comfortable do you feel asking a doctor what are my treatment options?

Answer 6

92% feel comfortable

Although its the approach of the doctor that determines this. In practice only 67% actually ask due to this.

Question 7

What is a citizens’ panel - how comfortable do you feel asking a doctor how likely are these to happen to me?

Answer 7

87% feel comfortable

Question 8

The following guidelines regarding osteoarthritis?

Answer 8

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

Question 9

The following guidelines regarding constipation?

Answer 9

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)

Question 10

The following guidelines regarding constipation?

Answer 10

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)

Question 11

The following guidelines regarding CKD

Answer 11

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.

Question 12

Fracture risk associated with the use of morphine and opiates?

Answer 12

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.

Question 13

Mortality after total hip replacement surgery?

Answer 13

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.

Question 14

Reduce Harm and Waste

Answer 14

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

Question 15

Which conditions are most commonly over diagnosed?

Answer 15

• Prostate and thyroid cancers,
  
  • Asthma
  • Chronic kidney disease
  • Attention deficit hyperactivity disorder

Question 16

What are the risk associated with over diagnosis to an individual?

Answer 16

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.

Question 17

Abnormalities for on scan in asymptomatic people?

Answer 17

• 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

Question 18

What would happen it 100 people over 60 years of age took sleeping tablets form more than one week?

Answer 18

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

Question 19

What is the issue with stricter diagnosis criteria with hypertension?

Answer 19

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

Question 20

Remember managing risk is personal to each patient

Answer 20

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.

Question 21

Become improvers and innovators?

Answer 21

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

Question 22

What five question should be asked to ensure you have all the information you need to make the right decisions about your care?

Answer 22

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?

Question 23

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’

Answer 23

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.