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Monday 26 September 2016 Instagram
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Don’t just do something, stand there!

Don’t just do something, stand there!

This week at the practice has been a very busy one, with hoards of people coming in with viral infections. They are all obviously feeling awful, but there is not a lot that we can do to help them, and since most of us clinicians have continued to struggle with similar symptoms, dealing with them can at times seem irksome.

We sometimes feel confused about what people are actually hoping to get from their consultation. Have they come for treatment or just advice? Or do they want validation that yes, they are ill, and that we give them "permission" to take a couple of days off work?

At this time of year, everyone is feeling tired and desperate for the holiday break. The City workers are stressed, those in retail or restaurants are working all hours, and the mums are rushing about with all the end-of-term school activities, quite part from endless Christmas shopping and cooking. And at the university my students are all panicking about assignments and exams, wishing they hadn't left everything until the last minute; the energy and enthusiasm at the start of the semester has waned. It just seems that bit harder for everyone to cope with the minor symptoms of ill-health than it did a couple of months ago.

It was with interest that I read yet another paper on the lack of evidence for the value of treatments for upper respiratory infections. This study looked at patients presenting to primary care with typical sinusitis symptoms: it compared treatment with antibiotics and intranasal steroids, alone or in combination, and concluded that neither improved symptoms any faster than placebo. An editorial points out that findings are consistent with previous studies, and urges clinicians to exercise caution when considering active treatments for patients with possible acute sinusitis. Yet more than 90% of such patients in the UK receive antibiotics!

So what is it that drives us to hand over that prescription? I think that we have a perception that patients are pressurising us for antibiotics and will be "disappointed" if they leave empty-handed. Yet my own experience is that, once you have listened to the patient's story, performed an examination, explained your findings, and given them time, most people are happy. It is very rare that I experience the "I have waited half an hour and I'm not leaving without a prescription" scenario.

I think we undervalue the therapeutic nature of the consultation itself - it is something about taking the patient's concerns seriously, making a good assessment and explaining your rationale. And avoiding making them feel that they have wasted your time (even if you do feel they could have managed this minor problem themselves). I am reminded of the quote "Don't just do something, stand there!", which I think is very appropriate slogan for managing a lot of minor illness.

So now I'm looking forward to a few days off and hoping that we will all be feeling a bit more resilient in the new year!

Reference
JAMA 2007;298:2487-96.

Your comments: (Terms and conditions apply)
"Nurses are not undervaluing the therapeutic consultations. It is just too difficult to fit this into 10mins" - Janet Igbanoi, NP, Chislehurst

"My husband sometimes has to remind me that my patients do not have the knowledge I have. Sometimes it is irksome to explain for the fourth or fifth time that the symptoms they are presenting with are viral and prescribing some steam and paracetamol is the appropriate treatment. I rarely find I have to argue the case as most people accept the diagnosis when given a full explanation. They want reassurance that they are not missing anything worrying. I do sometimes forget the extent of my knowledge and understanding and do occasionally need a reminder that I am the expert and that's why patients come to see me - Michelle Davidson, Somerset

"I don't think in general nurses undervalue the therapeutic nature of consultations. I think that they champion the cause of health and education advice.  One of the major problems that get in the way of therapeutic consultations is time constraint, particularly if working for an unsympathetic GP who is working towards QOF points and targets. Many GP surgeries I have worked for expect nurses to work as they do, i.e., quick consultation, cursory exam with an eye on the clock and out of the surgery quickly ready for the next patient all within five-seven minute framework. To do a proper consult with exam and then offer self-help and advice will take approximately five minutes longer, including advising the patient that if symptoms return as they are presented then a visit to the pharmacist will suffice. Most nurses realise that if a patient leaves without a prescription but with health education and the feeling that they have been listened to and taken seriously, they are less likely to return again and again for similar episodes as they have been empowered with knowledge. Nurses are taught as students that this is one of the fundamental requisites of their role and most that I have come across have not forgotten that just become jaded with government targets and management constraints" - Name and address supplied

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