The Doctor-Patient Relationship in the Covid era – how primary care doctors are learning on the run when age-old concepts are changing

Risky Business: lessons from covid-19

A BMJ article reports about a conference for clinical professionals are at the forefront of learning and innovation about, and sparked by, the pandemic. 

Primary care forever changed? Dr Martin Marshall -RCGP

It was fair to say that the primary care model had not changed in decades, Martin Marshall, chair of the Royal College of General Practitioners council, said. But it was propelled forward “dramatically” in just a few weeks in April. And, he said, such changes are more likely to stay the longer the pandemic continues and they form a new normal.

Marshall highlighted three ways in which general practice has changed forever: technology, administration, and public health. Before the pandemic a small number of practices used remote triage to direct patients to the most appropriate services—now 100% of practices do so. Before covid-19, 70-80% of consultations were face-to-face—that’s now just 15-20%. There has been a massive increase in remote diagnostics and monitoring as well. Marshall did, however, point out that the systems most in use are still the “old tech” of phone calls and email.

He said there has been a 30% reduction in “bureaucracy” such as contracts and appraisals, to the relief of many in general practice. This has restored a system of “high trust, less checking” that he hopes will remain after covid-19 passes.

That trust is crucial in the role of GPs in the public health effort. GPs are a first contact for patients and act as a link between them and the public health network, thus supporting infection control. That must be maintained, Marshall said, while recognising that it may take away from standard care duties that only primary care can fulfil. We don’t want to risk diluting what it is that GPs do best, including care for longer term “diseases that don’t go away,” such as cancer and childhood conditions.

Litigation – Pallavi Bradshaw, Medicolegal lead

(I know this may not be relevant for Sri Lanka just now as rarely do our patient take us to Court! -but watch the space – Covid may change all of this in a very short time)

‘Covid-19 has changed the doctor-patient relationship forever’ said an medico-legal expert.  While the crisis may have “escalated the breakup between doctors and patients there may be a new love affair between society and the profession.”

Patients have been physically and emotionally separated from doctors by PPE, remote consulting, and fear of accessing healthcare at all, Bradshaw said, which has strained the trust and communication on which the doctor-patient relationship is built.

Only 1-5% of patients litigate after negligent treatment (in UK), but poor communication is often a differentiating factor between those who are sued and those who are not.

This is a risk when telemedicine is impaired by the loss of verbal and non-verbal cues, and impatience. One study that showed doctors on remote consultations interrupted patients after 12-18 seconds when completion of the story would have taken 90 seconds.

If the current respect and empathy shown by the press and public towards medical workers would translate into an increased tolerance of medical error, society may understand that stretched staff and resources will not always deliver quality care and, on occasion, patients will be harmed.

Despite the goodwill, there are fears that a “tsunami of claims” is approaching, owing to a disruption in care and aggravated by economic hardship, the authors said. With outstanding NHS liabilities estimated at over £80bn (€89bn; $100bn), there is a looming worry over patients seeking compensation at this time.

Sri Lanka

How would the Sri Lankan react and behave? The remote consultations are increasing and even the private hospital Channel centres are offering remote consultations. In addition Telecommunication agencies that partner with leading doctor associations offer call your doctor services with very little focus on ethical aspect and patient safety.   

A study from Nigeria

A study from Nigeria about the doctor-patient relationship is interesting. The objective of the study was to determine the effect of COVID-19 pandemic on the doctor-patient relationship.

The study was a cross-sectional study conducted in a tertiary health facility and  involved all the doctors working in the hospital.  Patients that attended the general out-patient clinic of the hospital were selected using convenience sampling. 

There was disparity in some of the studied aspect of the doctor-patient relationship as reported by the doctors and the patients. The prominent being the social distancing practice which almost all the patients (91.6%) said that it has affected their relationship with their doctors while only about half of the doctors (52.7%) agreed to this assertion. However both parties agreed that the level of physical examination have reduced to the barest minimum. Conclusions: The present COVID-19 pandemic have affected the doctor-patient relationship adversely.

To Be a Great Physician, You Must Understand the Whole Story

Heart Shape with doctor

2007. Dr. Robert Centor, Professor of Medicine at the University of Alabama, Birmingham.

‘We physicians all have heroes during our training. We all remember the great physicians. I contend that the great physicians differ from the good physicians because they understand the entire story. Only when we understand the complete story do we make consistent diagnoses.

Each patient represents a story. That story includes their diseases, their new problem, their social situation, and their beliefs.

How do we understand the story? We must develop excellent communication skills and gather the history in appropriate depth. We must perform a targeted physical examination based on the historical clues. We must order the correct diagnostic tests, and interpret them in the context of the history and physical exam. Once we collect the appropriate data, we then should construct that patient’s story.

The story includes making the correct diagnosis or diagnoses. The story must describe the patient’s context. Who is this patient? What are the patient’s goals? How might the patient’s personal situation impact our treatment options?

Sir William Osler said, “The good physician treats the disease; the great physician treats the patient who has the disease.” The great physician understands the patient and the context of that patient’s illness.

For you physician readers, take Osler’s challenge. Be a great physician. Understand the full story. Make correct diagnoses. Consult the patient in designing the treatment plans that best fit that patient.

Follow the results with consistency and compassion. By so doing, you will not only be providing the highest quality medical care; you will also be living up to the ideals of William Osler and those of Tinsley Randolph Harrison – the greatest of physician role models.

You can even watch a 3 minute video

Connecting With Patients—The Missing Links

Can an Evidence-Based Approach Improve the Patient-Physician Relationship_2

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