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Ditching the intercom - the benefits of a short walk

Rob Walker - 25 Jan, 2018

As GPs, and doctors in general, we have a long history of not looking after ourselves very well. Far too often we are guilty of trying to secure other peoples oxygen masks without sorting ours out first. I caught myself doing this before Christmas - telling the umpteenth person they need to do more exercise, and ‘you just need to build it into your daily routine and it becomes much easier’, before reflecting on the fact that I had got out of my room about 4 times in an 11 hour day and the sum total of my daily activity was squat-all. I had stiff legs, a bladder near my umbilicus and was running a high risk of a pressure sore on my backside, not to mention feeling isolated and grumpy. So I read with great delight an article in the January BJGP (http://bjgp.org/content/68/666/28) by a GP from Birmingham who had taken to ditching the intercom and gone back to calling his patients from the waiting room. Perfect I thought - more exercise (tick), New Year resolution (tick), reflection/practice changing article/more points for my appraisal (tick and polish halo).

So for the month of January I have gone ‘old-school’ and am walking down the corridor to call my patients from the waiting room. There is no doubt that the extra 1500 odd steps per day has helped me feel better in myself, as much psychologically as physically. I feel more alert and I’m sure this is making me consult better. But in Dr. Wlikinson’s article, he points out a number of wider benefits of this extra activity and I agree with many of those. As he points out patients seem ‘impressed with my simple example of modifying one’s behaviour to improve health’. We can tell our patients hundreds of times to increase activity and recommend various websites and apps, but I’m sure a bit of ‘practice what you preach’ has to help. I always struggled to remember consultation models, but I do vaguely remember one of the points from Neighbour’s ‘Inner consultation’ and the importance of connecting with the patient at the beginning and building rapport - greeting people in the consultation with a smile and a ‘Hello’ with some pre-amble chit-chat down the corridor seems to work very well in this regard and starts the consultation on a positive note. We were always taught as medical students to ‘observe the patient first’ and walking to the waiting room allows 30 seconds of observation before the consultation proper starts - you can diagnose frailty before the patient has left the waiting room, pick up the antalgic gait from the patient with hip OA who is heading for a hip replacement, and be reassured with the feverish child who sits quietly on mums lap in the consultation room not interacting, knowing that she is actually quite well as she walked down the corridor chatting away before getting a bit scared in your room. Observing the waiting room also allows you to get a feel for what is happening at the coal-face day to day - 'note to brain reception queue is terrible on Friday mornings - better get the PM to look at staffing levels..’

So finally back to Neighbour’s consultation model, and the final stage which I’d completely forgotten about - ‘housekeeping’. This isn’t about tidying up the notes or checking you’ve done your QoF points but making sure you are psychologically finished with the last consultation and ready for the next - ‘Am I in good condition for the next patient?’ Well, 15-30 seconds of micro-mindfulness whilst walking up the corridor will certainly help.


Rob Walker


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TIME FOR A DRIER JANUARY?

Rob Walker - 10 Jan, 2018

Andy is 36, is usually fit and well and you rarely see him. But he’s come in because he’s struggling to sleep and is asking if he can have a few sleeping tablets ‘just to re-set things’. He says he gets to sleep fine, but wakes often and does not feel like he has much restful sleep and feels groggy in the morning. His mood seems low and he says he’s had some arguments with his wife over Christmas. It quickly becomes clear that his alcohol intake is likely to be the major problem. He had always drunk quite heavily at the weekend, getting through at least 2 bottles of wine, but his weekly drinking has steadily increased to the point where he rarely has a night without alcohol and often drinks 2-3 glasses of wine or beer per night. He has now got into a vicious cycle of having an increasingly large night-cap as well to try to help him sleep. It’s always difficult to estimate home measures, but he is drinking 40+ units/week. He has no symptoms that suggest dependence. 

We know alcohol related illness is a major issue for the health service. The latest NHS statistics (for 2015/16) show that 1.4% of all deaths in the UK were due to alcohol, similar to the previous year, but still an increase of 10% since 2005. The number of hospital admissions directly attributable to alcohol was 2.1%, an increase of 3% from the previous year and an increase of 22% since 2005. One measure suggested by NICE in 2010 (https://www.nice.org.uk/guidance/ph24) was that GPs (as well as a broad range of other health and non-health professionals) should screen for, and offer, brief interventions for risky alcohol consumption. A systematic review in 2016 (http://bmjopen.bmj.com/content/6/8/e011473) suggested that alcohol brief interventions (ABIs) can play a small but significant role in reducing alcohol consumption. However, an article in the BMJ in 2017 (http://www.bmj.com/content/356/bmj.j116?variant=full-text&sso=) questions both the evidence and practicalities for implementing ABIs in General Practice - they point out that ~90% of patients that drink too much alcohol also have either a poor diet, do too little exercise or smoke; should we use our limited time to prioritise ABIs over other lifestyle interventions, especially when it is recommended ABIs should take 5-15 minutes?

Whether or not alcohol screening and intervention is feasible or effective in primary care at a broader level, it is clear Andy needs help with his drinking. So what options have we got to help him? It certainly would be sensible to do a screening questionnaire as recommended by NICE e.g. AUDIT (https://www.alcohollearningcentre.org.uk/Topics/Latest/AUDIT-Alcohol-Use-Disorders-Identification-Test/) on which he scored 14, putting him in the ‘increasing risk’ category but close to ‘higher risk’. He’s got pretty good insight into the fact that he is drinking too much and that it is probably impacting both his health and his relationships. One option at this stage might be to sign-post him to some self help resources and offer him a review appointment to see how he is getting on. There is an excellent NHS leaflet which, among other things, explains the AUDIT score and promotes a ‘booze tracker app’ (https://www.alcohollearningcentre.org.uk/Topics/Latest/Identification-and-Brief-Advice-Tool-2017-revised-April-2017/) which you can give to him, and I would highly recommend the ‘drinkaware’ website which has got some very good practical advice for cutting down on alcohol (https://www.drinkaware.co.uk/advice/how-to-reduce-your-drinking/how-to-cut-down/).

Another option would be to bring him back for a session of brief structured advice, as recommended by NICE. It is recommended this should take 5-15 minutes and should be based on the FRAMES model:

Feedback: 

Give feedback on the risks and negative consequences of alcohol use. Seek the client's reaction and listen.

Responsibility: 

Emphasize that the individual is responsible for making his/her own decision about his/her alcohol use.

Advice: 

Give straightforward advice on modifying alcohol use.

Menu of options: 

Give menus of options to choose from, fostering the client’s involvement in decision-making.

Empathy: 

Be empathic, respectful, and non-judgmental.

Self-efficacy: 

Express optimism that the individual can modify his or her alcohol use if they choose.

I hope those few pointers will give you some tools for tackling excess alcohol consumption, and if you want further training, options for e-learning courses on alcohol identification and brief advice (IBA) can be found here: https://www.alcohollearningcentre.org.uk/eLearning/IBA/alcohol-iba-in-primary-care-e-learning-course/

Rob Walker


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