Transcript Pain Clinic
Skills to Manage Frequent Attenders in Primary Care Dr Venetia Young Aims of today • Understand how the body produces symptoms when a person is distressed and be able to explain it • Lots of tips to deal with these symptoms in short consultations • Learn about the stress cycle • Learn about the molecules of emotion • Learn about breathing • How these relate to CHD, COPD, DM, Bipolar Disorder, Chronic pain… • How thinking about frequent attenders and heart sink patients can lead to service improvement in Primary Care and maybe other services…. • Solutions and a new style of thinking and consulting Bishopyards Surgery • Small market town – 20,000 • 5500 patients 5 doctors (3WTE) 2 nurses, pharmacist • Consultations with GP in surgery 5 or more Jan – March 2007 • 163 patients 1025 appts 3% of list • 25% ADT • Top 50 33% on ADT • One child • High proprortion middle aged women Audit • Top5 – 3 major Mental Illness all in contact with CMHT, 1 severe eating disorder, 1 complex social problem • 10 depression anxiety – 8 on waiting list for PCMHT • 2 severe illness - both died • 7 straightforward physical illness • 26 multiple symptoms – dyspepsia commonest Sheffield study • Waller and Hodgkin 2000 General Practice demanding work • 9 city practices • 1.3% of list 8.3% consultations (20 pa) • 3.6% generated 17.6% consultations (15pa) • 42% on ADT • 1/3 repeated the behaviour the next year How was this managed? • • • • • • Discussed with GPs 10 patients in referral process with PCMHT CMHT contacted re top 3 Anorexic patient admitted – mother and sister Social problem family – regular appointments Remaining ones noted and VY worked with 15 as they attended: genogram, ICE, stress cycle, hyperventilation, HADS and ADT where appropriate • 3 patients offered regular routine FU continued • Training all staff on Stress management and Health Related Anxiety. Five finger exercise • 2 GPs, HCA and pharmacist on Positive Mental Training course • Regular meetings with HV and school nurse: became safeguarding meetings • Better focus with PCMH team • Change to green slip for appointments • Cultural shift to active management • Less use of locums One year on • 44 patients • One consulted 10 times – SMI plus new diagnosis of pulmonary fibrosis • Less than 1% list • Even age distribution except 20-40 • More female • Saving 200 appts over 3 months Further update • • • • • • • • • • • • • Two practices have merged with different FA problems GP trainees and medical students given data to audit Monthly PCMH meeting: school nurse, HV And CMHT – safeguarding MIND and PCMHT doing condition management programme Menopause evening – sandwich generation commonest FAs COPD afternoon Training for all staff on personality disorder, recognising abuse and domestic violence GP and nurse practitioner consultation skills training Locality practices all doing FA audit and being surprised! Ideas in pipeline are a group for women 45-65 who are FAs, pain management group and mindfulness group Consideration of employing MH practitioner rather than GP – a missing tier in service delivery Statistical analysis – significant difference especially for over 40s EMISweb change and telephone triage What are the patients needs? • Have the workings of their bodies explained to them. • Distress – relationships, work, school, money, housing • Depression – referral and ADT monitoring • Anxiety disorders - especially HRA need recognition • Major MI treated and managed better between team and surgery • Good quality self-help literature including books • Good quality referrals Skill implications for whole team • • • • • • • • • • Active management not reactive Good assessment Eliciting patient’s backgrounds Explaining stress and its effect on body Hyperventilation Managing affect in consultation and on the phone Therapeutic skills for watchful waiting Finding the Frequent attender Noticing the medication abuser Using self help materials to empower the patient Primary care team and the wider community • Community resources: where there are gaps patients will present in the surgery: young Mums, middle aged women, elderly • Mental health organisations • Social Care organisations • Third sector Your symptoms • With next person talk for 5 minutes about the symptoms you have experienced in the last week. Experience of Symptoms • 80 - 90 % population have at least one symptom a week. (Anderson et al 1968, Hannay 1978.) • Women aged 20 - 44 have on average 10 symptom days out of 28 days. (Banks et al 1975) • Medical consultation 1/37 symptom episodes (Banks et al 1975) Diabetes • … • … • … Gastroenterology • … • … • … Gynae • … • … • … Respiratory • … • … • … Neurology • … • … • … Cardiology • … • … • … Pain Clinic • … • … • … Tital Three year incidence of 10 common symptoms and the proportion with organic disease 12 10 8 6 4 2 0 Kroenke & Mangelsdorff 1989 Explaining the stress cycle • Charles: 72, recently had stent put in after short episode of new angina. Op technically a great success • Comes into the surgery with feeling that he is going to have a heart attack, cold, sweaty, hands tense, head feels like exploding. • Explain the stress cycle: always a worrier, likes to be in charge, never been in hospital, felt very vulnerable, not enough time to adjust to idea of operation CHD and stress/anxiety/panic • • • • • • • Panic disorder is present in…. 15-20% of people with palpitations 33% of people with chest pain and no CHD 34% of people with proven CHD Panic disorder alters cardiovascular responsiveness 55% of patients with known CHD hyperventilate 66% experience their typical angina pain when they hyperventilate • higher BP and cholesterol • men with high score for anxiety have 6 times increase in sudden cardiac death Continued…. • Investigations • 75% of people with a negative angiogram who have panic disorder continue on multiple treatments • more follow up, • more testing, • more investigations. • 50% remain disabled or unemployed • Reference • Jeejeebhoy, Dorian and Newman - Panic disorder and the heart: a cardiology perspective. Journal of psychosomatic research (2000) 48 393-403 HeartMath Tip • Take five minutes several times a day, whether or not you’re feeling especially stressed, to try these simple steps adapted from the HeartMath Attitude Breathing® tool. • Focus on your heart as you breathe in. • Concentrate on a positive feeling or attitude as you breathe out. • Lock in this new feeling as you continue to breathe it in and out through your heart. • As you become adept at using this HeartMath tool, select new feelings and to help you "de-stress" as needed. Breathing too much • Neuro: parasthesia, dizzy, headaches, Loss of concentration, visual disturbances • CV: cold hands/feet, palpitations, chest pains, light headedness, tachycardia • MS: muscle aches, cramps, general weakness and fatigue • GI:heartburn, bloated feeling, abdominal distension, dry mouth, belching and flatulence • Resp: sigh, yawn, air hunger, inability to take deep breath, irritable cough, apical breathing, breathless • Other: speech, vocabulary, COPD/asthma - breathing • 55 year old woman. Thought she was done for with mild COPD. Life more limited, not going out much with husband, children all left home, blamed herself. Came to COPD afternoon • Breathing • Relaxation • Remembering what she liked doing • ‘This has saved my life’ Severe COPD • 65 year old woman – couldn’t breathe, chest muscles all tight, frightened/panicky • O2 sats 91% RR 20 upper chest and shoulders high • O2 sats 96% RR 10 shoulders low • Gobsmacked! • Belief had been that she simply had to breathe more because of her COPD not less! Diabetes • Joan – 65 with Type 2 DM, Anxiety and Barratt’s oesophagus • Poor control HbA1c 8.8 • Doctor appts every 2 days phoning nurse in between – health anxiety • CBT • Work with family • Breathing 1 year on • Routine appts every 4-6 weeks – occasional attendances in between • Diabetic control good HbA1c 6.6 – reduced oral meds • Coping strategies – breathing and managing her family relationships BATHE technique • • • • • Background Affect Troubles you? Helps Empathic remark Solution focussed consulting • • • • • • • Pre appointment change Problem description Goals Scaling Exceptions Miracle question Feedback, homework and compliment Margaret 63 • Hypertension, neck pain, IBS, back pain, irritable bladder, fatigue, asthma, codeine addiction Her life • • • • • • • • Elderly mother frail Sister with MS with 2 children Brother in care home cerebral palsy Divorced 4 children Adult son living at home with his 8 year old. 2 bedroom house Compulsive carer Solutions • • • • • • • • • Eden carers – aromatherapy Help for her mother and sister Making sense of it all with a genogram Understanding she hadn’t got cancer Getting her friendships back Exercise Problem solving Setting boundaries with son and grandson Women who love too much by Robin Norwood Resources • Positive mental training CDs • Mentor and Northumbria leaflets – anxiety/stress/relaxation • Respiratory physiotherapist – • First Steps - Primary Care MH Team– anxiety management (including health anxiety) • Long term conditions pilot - through First steps • Yoga • Tai Chi • Meditation/mindfulness – Buddhist group • Relaxation group - MIND References and websites • • • • • • • • • • • • • • Dean Ornish – Love and survival Dean Ornish - Reversing heart disease Susan McDaniel - Family Oriented Primary Care – good chapter on psycho-bio-social approach to MUS www.heartmath.org Thich Nat Hanh – the Miracle of Mindfulness ‘Overcoming Anxiety’ and ‘Feel the Fear’. Self help leaflets Health Anxiety Inventory - HAI www.primhe.org.uk presentations and David McDaid on the economics of MUS www.neurosymptoms.org Dr Jon Stone www.positiverewards.co.uk Dr Alastair Dobbin – self-hypnosis ‘10 minutes for the family’ Routledge 2004 Asen Tomson Tomson and Young ABC MUS Chris Burton RCGP MUS guidance Emotional healing for dummies Dr David Beales Diabetes • … • … • … Gastroenterology • … • … • … Gynae • … • … • … Respiratory • … • … • … Neurology • … • … • … Cardiology • … • … • … Pain Clinic • … • … • … Tital Reflections on the elephant in the consulting room. • What are your training needs to equip you for a confident career in General Practice? • How could GP trainees alter the ways of working of all the departments they pass through during their training? Dr Venetia Young Named GP Eden - Safeguarding Lonsdale Unit Penrith Hospital Bridge Lane Penrith Tel: 01768 245666 email [email protected]