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Empathy in General Practice - a personal (and evidence-based) view

Rob Walker - 18 Oct, 2018

Empathy is a subject I’ve taken more interest in over the past few years. I took my daughter to an exhibition ‘A Mile in my Shoes’ on the Southbank a couple of years ago. In the giant ‘shoe box’ are a series of shoes donated by local people and you physically put their shoes on and go for a walk while listening to an audio of the story of their life that has been pre-recorded. I listened to a fascinating insight into the life of a local palliative care consultant, while my daughter had her eyes opened by listening to the story of a young boy recently arrived in London as a refugee.

Anyway, what has this got to do with General Practice? Ever since that experience, I have been more aware of the importance of empathy in the consulting room and there were two articles in the September 2018 BJGP that caught my eye - one a cross-sectional study from the Netherlands looking at the difference in how GPs and patients scored the GPs ability to empathise; the second was an editorial exploring the meaning and importance of empathy in General Practice.  

There is still no universally accepted definition of empathy but the one I most like suggests that empathy is the ‘art of stepping imaginatively into the shoes of another person, understanding their feelings and perspectives, and using that understanding to guide your actions’. I think that encompasses nicely what we are doing in a consultation when trying to connect with our patients. Empathising with patients is a key part of forming a therapeutic relationship and a systematic review in 2013 concluded that ‘There is a good correlation between physician empathy and patient satisfaction and a direct positive relationship with strengthening patient enablement. Empathy lowers patients’ anxiety and distress and delivers significantly better clinical outcomes’. 

Evidence consistently shows that patients rate doctors highly in terms of empathy. But what is our perception as to how well we empathise with our patients? The study in this BJGP interestingly showed that patients consistently scored the doctors better at empathising than the doctors did. So why do we not think we are doing as good a job as we’re actually doing? Is it all the negative messages about GPs, General Practice and the NHS in general? We may not be able to metaphorically step into our patients shoes and go for a 20-30 minute walk with them in our consultations, but the evidence would suggest that despite all the pressures we are under, our ability to step into our patients shoes and empathise with them is still good. In the constant drive for more efficiency in the NHS, this message must not get lost: empathy is a crucial aspect of the therapeutic relationship in General Practice, it delivers better patient outcomes, and primary care is still doing a great job in this regard. 

And finally, where does NB Medical fit in with all of this? Yes, we are here to do all that reading and condensing of the literature to keep you up to date with all the latest research and guidelines, but as we always say on our courses that is only part of the story. YOU are the experts in delivering care to YOUR patients. Learning to walk in your patients’ shoes can be one of the most powerful and therapeutic ways to do this.

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Top 5 Learning Points from 2018 European Hypertension Guidelines

Simon Curtis - 4 Oct, 2018

Late last year the new American Hypertension Guidelines 2017 managed to supplant the NICE lipid guideline of 2014 with the dubious honour of being the most controversial guideline ever published. They re-defined hypertension, set ambitious treatment targets and created a huge debate around their potential for overdiagnosis and overtreatment. This month has seen the publication of new European Hypertension Guidelines 2018 produced by the European Societies of Hypertension and Cardiology. These guidelines have some key differences but are broadly similar to the American ones and propose significant changes in practice. We have read the guideline (all 98 pages of it!) and bearing in mind the ‘guidelines not tramlines’ mantra these are our Top 5 learning points:

  • Wider use of out of office BP measurement with ambulatory (ABPM) and especially home (HMBP) monitoring when ‘logistically and economically feasible’. Hypertension is defined as a persistent elevation in office systolic BP ≥ 140 mmHg and/or diastolic ≥ 90 mmHg, but with adjustments for HBPM (mean ≥ 135/85) and ABPM (mean ≥ 130/80).
  • Thresholds for starting drug treatment are ≥ 140/90 office for most patients up to age 80, but with a more relaxed threshold of ≥ 160/100 over 80. Very high-risk patients, e.g. with established cardiovascular disease, may be treated in the ‘high normal’ range of 130-139/85-89.
  • Elderly people should have their hypertension actively managed but according to biological rather than chronological age with consideration of frailty, independence and tolerability. They should not have treatment withheld purely on the basis of age.
  • Start treatment with drug combinations using a renin angiotensin drug with either calcium channel blocker or diuretic for most patients. The guideline sets out to ‘normalise’ the concept of starting with two drugs, the rationale being that ‘monotherapy is usually inadequate, most patients need combinations, and this will improve speed, efficiency and predictability of BP control’. They recommend that ideally these should be in single pill combinations to improve adherence and recommend this strategy for all patients except those of lowest risk or frailer very old patients.
  • Target: treat all patients to achieve a target of <140/90 and provided that treatment is well tolerated treated BP levels should then be targeted to <130/80 in most patients aged under 65. For patients aged over 65 a more relaxed systolic target of 130-139 is recommended.

Doubtless these guidelines will prove as controversial as the American ones. But we GPs know that guidelines should be individually applied according to clinical judgement and patient choice, and that for hypertension lifestyle change comes first and people at higher absolute risk should be our treatment priority. As a recent BMJ editorial pointed out all the debate and controversy over thresholds and targets should not distract from the main issue of under treatment of people already at high risk. A greater use of out of office measurement, a first target of getting all patients under 140/90 and offering patients the option of quicker better control with combinations of drugs seem a start along this road. 

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