Complexity

1
Complexity

• South Birmingham VTS 2007

2
AIMS

• To heighten awareness of the complexity of
  medical care, by considering a clinical case
  presentation.
• To determine strategies to help deal with
  patients with complex problems.
• To help you see the bigger picture.

3
The Case

• A 79 years old man with diabetes, IHD, PMR, COPD
  who is on a host of medications.

4
Current Medication

• Traxam gel 3
• Viscotears
• Eumovate oint
• Aspirin disp 75mg od
• Prednisolone 1mg 4 a day
• Senna prn
• Anusol oint
• Anusol suppository
• Astra Tech Lofric catheter
• Ipratrop bro Salbutamol nebuliser soln
• Salbutamol inhaler
• Salmeterol Fluticasone cfc inhaler
• Sudafed
• GTN tabs 300mcg
• Digoxin 125mcg od
• Frusemide 40mg 1 bd
• Atorvastatin 80mg 1 od
• Candesartan 8mg od
• Diastix

5
Recent investigations

• SEE GRAPHS

6
What issues are raised by this case?

• Please explain your answers

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Issues raised?

• Comorbidity/multimorbidity
• Polypharmacy
• Dealing with uncertainty
• Importance of psychosocial factors
• Continuity of care
• Collusion of anonymity
• Doctor hopping
• Heartsink patients?
• Computerisation of medical records/Connecting for
  health www.connectingforhealth.nhs.uk

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Heartsink patients

• Risk Factors Different authors have found a
  variety of criteria that predispose a person to
  be a heart sink. The following tend to feature in
  many lists
• Female preponderance.
• Over 40.
• Socially isolated, usually single, separated or
  widowed or marital problems.
• Low tolerance for just putting up with minor
  illness.
• Low education and social class.
• They may well have serious chronic illness too.

9
Heartsink patients The features that vex doctors
are legion and include

• constant and delighted assertion that the
  treatment was useless.
• failure to take responsibility for their own
  actions like smoking or obesity.
• long as well as frequent consultations.
• many nebulous complaints all at once.
• want treatment for various children and relatives
  (without notes).
• demand inappropriate certificates.
• repeat the same life stories incessantly.
• ask for inappropriate therapies.
• throw "the useless" medications across the
  consulting desk.
• demand treatment triggered by a TV advertisement
  or the Internet.
• demand their "rights" before explaining the
  problem.
• are over familiar.
• are happy to talk incessantly, but not listen to
  a word you have to say.
• know you can't help but .................

10
Heartsink patients

• O'Dowd TC Five years of heartsink patients in
  general practice. BMJ 1988 Aug 20-27297(6647)528
  -30.abstract
• Ellaway A, Wood S, Macintyre S Someone to talk
  to? The role of loneliness as a factor in the
  frequency of GP consultations. Br J Gen Pract
  1999 May49(442)363-7.abstract
• Jiwa M Frequent attenders in general practice
  an attempt to reduce attendance. Fam Pract 2000
  Jun17(3)248-51.abstract
• Gill D, Sharpe M Frequent consulters in general
  practice a systematic review of studies of
  prevalence, associations and outcome. J Psychosom
  Res 1999 Aug47(2)115-30.abstract
• Mathers N, Jones N, Hannay D Heartsink patients
  a study of their general practitioners. Br J Gen
  Pract 1995 Jun45(395)293-6.abstract
• www.patient.co.uk

11
Collusion of anonymity

• Michael Balint, The Doctor, his patient and the
  illness 1957.
• Collusion of anonymity No one takes
  responsibility . Patients get passed around from
  one doctor to another.
• Drug doctor
• Doctors have feelings
• The Flash
• Primary and secondary gain (kudos, sick-role,
  tyranny, compensation, benefits).

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Continuity of care A Concept revisited.

• The concept of individual doctor/patient
  continuity has served its time. We must ensure
  that the benefits historically associated with it
  are translated into tem-based care. Amongst
  these, the quality of communication between
  patient and doctor and the quality and
  accessibility of the clinical records are
  uppermost.
• Dr Douglas Fleming EJGP 20006140-5

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Multimorbidity Chronic diseases what happens
when they come in multiples? Smith S, ODowd T.
BJGP 2007 57 268-70

• Multimorbidity is the coexistence of two or
  more chronic diseases in an individual.
  Prevalence studies indicate that it is the normal
  state of affairs, especially in patients over the
  age of 65 years
• The commonly used term comorbidity implies
  that there is an index disease to which
  coexistent diseases relate and may share an
  aetiology and perhaps a solution. In clinical
  practice individual patients often suffer from a
  collection of chronic illnesses which may or may
  not have a common aetiology, but which require
  greatly differing and often incompatible
  management
• Little research is available for multiple
  coexisting conditions, as individuals with
  multimorbidity are often excluded from such
  studies to minimise bias.

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Polypharmacy

• What is already known on this topic
• Patients who receive polypharmacy have low
  levels of compliance
• The complexity of the treatment regimen is
  associated with non-compliance, and
  non-compliance is associated with increasing risk
  of death in a stepwise manner
• What this study adds
• Periodic telephone counselling by a pharmacist
  of non-compliant patients receiving polypharmacy
  improves compliance with treatment and reduces
  mortality and use of healthcare resources
• Effectiveness of telephone counselling by a
  pharmacist in Reducing mortality in patients
  receiving polypharmacy randomised controlled
  trial
• Wu et al BMJ  2006333522 

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• Which strategies can we use to deal with
  patients with complex problems in primary care?

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Suggested strategies

• Consider whole person/situation
• Personalised lists/owning the patient
• Say noto referrals or more drugs
• Adequate time e.g. double appointment
• Deal with problems in bite-sized chunks
• See with/ involve a relative of the patient
• Use the computer constructively, organise
  records, summaries, medication, use prompts
• Use help e.g. Practice nurse, community matron,
  relatives

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The Art of strategy

• Those who have supreme skill use strategy to
  bend others without coming into conflict
• General Sun Tzu (Chinese warlord) 2500 BC

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And this is what we want to avoid.

• OK, so if all else fails we could always just go
  down the pub!

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QOF screening for depression in chronic diseases
e.g. DM, IHD

• During the past month, have you often been
  bothered by feeling down, depressed or hopeless?
• During the past month, have you often been
  bothered by having little interest or pleasure in
  doing things?
• An answer yes to either of the two questions
  warrants further enquiries about possible
  depression.Asking these questions has been shown
  to increase the specificity of the screening
  questions from 67 to 89, reducing the incidence
  of misclassification as depressed. BMJ 2003 327,
  1114-6