Sending love at Christmas…. by Mairi Small

Christmas is inextricably linked with love…..

Dean Martin sings about having his “love to keep him warm” – if you would like to spend a couple of minutes warming the cockles of your heart click here –

Smokey Robinson and his Miracles feel that if their baby loves them too, it would be Christmas every day and annually, in early December, we’re reminded that all Mariah wants for Christmas is youuuuuuu. (The remainder of the song choices in the collage are for you to ponder whilst digesting your turkey on Tuesday)

In Cardiac Rehab we love to sing and have a soundtrack to each of our weekly exercise sessions which are held in venues throughout D&G. Sometimes, the music choices are a little bit Homes under the Hammer-esque…. “Dont Go Breaking My Heart”, “Under Pressure”…..  And of course who could forget the dulcet tones of Billy Rae Cyrus belting out “Achy Breaky Heart” in years gone by (for those under 30 reading this, Billy is Miley Cyrus dad). But C/R isn’t “just an exercise class” as anyone who has ever had experience of our service will testify – so what do we actually do?!

Well, since “last Christmas”, the C/R service in D&G has supported over 500 individuals following a cardiac event. The British Association for Cardiovascular Prevention and Rehabilitation (BACPR) define priority groups for inclusion as post MI, coronary revascularisation (stents or bypass) and heart failure.  Locally, we also include those with a diagnosis of angina, post valve repair/replacement, post implantation of cardiac defibrillators and resynchronisation devices, post heart transplantation and ventricular assist devices and adult congenital heart disease.

The service was set up in D&G in 1990, with an extensive, worldwide evidence base being consolidated since – C/R reduces cardiac mortality by 26% and unplanned hospital admissions by 18%. Currently based in Cluden Cardiac Unit in Crichton Hall, we are set to move into Mountainhall in early 2019. We see inpatients in both DGRI and GCH and run out patient clinics regionwide. We are a small team of nurses and physios who work closely with a wide range of health care professionals, services and organisations.

Although C/R nationally is undergoing a programme of modernisation in line with Scottish Government priorities, it maintains its traditional “menu based approach” with patients choosing the components that matter to them.  So, whats on the C/R menu this Christmas, and beyond?!

To start

Identification, referral and recruitment of eligible patient populations – referrals tend to be picked up during in patient stay or from tertiary centres but we also accept referrals from other HCPs.  Referrals can be sent electronically to – dumf-uhb.CardiacCommunication@nhs.net

Early initial assessment of individual patient needs – including medical history (a significant proportion of patients will have one or more co-morbidites), relevant investigations, social determinants of health, lifestyle risk factors, psychosocial health and medical risk factor management.  This may take place in hospital, the patients home or out patient clinic and may be completed over more than one contact.

Agreed personalised goals – to be reviewed throughout the episode of care.  This really is the “what matters to you” bit of the programme.  Goals may range from “aim for 3000 steps a day” to “get back to work” to “get back to singing with the choir”.

To follow

Health behaviour change and education – this may include addressing cardiac (or other) misconceptions and illness perceptions that may lead to increased disability and distress, support of the patient’s significant other/s, goal setting and pacing skills, and facilitation of self management skills. Discussions may include – pathophysiology and symptoms, management of risk factors such as BP and lipids, occupational/vocational and driving advice, resumption of sexual relations and dealing with sexual dysfunction.

Lifestyle risk factor management – a trio of physical activity and exercise, healthy eating and body composition and tobacco cessation.

Individualised advice on ADLs and a tailored activity and exercise plan aims to increase physical fitness as well as reduce sedentary behaviour. Home based exercise plans are offered for those unable to uptake on traditional group exercise sessions and patients also get the opportunity to exercise within local authority leisure facilities. We are currently exploring the use of technology by way of short term loan of Fitbits to ascertain baseline activity levels and encourage an increase in an individuals “active minutes”.

Following baseline assessment of dietary habits, weight, BMI and waist circumference, a focus is on the adoption of a cardioprotective diet which encompasses healthier dietary choices, correcting misconceptions about diet and health, and body weight maintenance (or reduction if appropriate).

Patients who are smokers at the time of assessment are referred to the Quit Your Way service in addition to the C/R team providing education and support in the preparation and attempt at smoking cessation.

Psychosocial health – all patients are screened for psychological distress using validated tools and individual assessment allows for discussion regarding illness perceptions and self-efficacy for health behaviour change, and to determine levels of social support. Patients are encouraged to practice relaxation strategies or mindfulness exercises regularly and are offered taster sessions as part of the programme.

Medical risk management – optimisation of cardioprotective therapies is guided by regular measurement of BP, heart rate and rhythm, glucose and lipids. This provides an opportunity to discuss dosage and adherence with the patient and address their beliefs around their medication regime. It is hoped that some of the team can become independent prescribers to streamline the process of up titration of the secondary prevention medication in the longer term.

BHF Heartstart training – all patients and their family/friends are invited to attend this two-hour session to learn how to recognise an MI/cardiac arrest and deal with a life threatening emergency – perform CPR, access and use an AED, deal with choking and serious bleeding. This year 239 individuals across D&G have attended a Heartstart session run by the C/R team.

To finish

Final assessment of individual patient needs – to determine the effectiveness of our interventions, we are currently reorganising our service to create time for a more comprehensive final assessment to take place. To date this has been done quite informally but we feel it would enhance the patient experience to revisit baseline measures and formalise the ongoing management plan collaboratively. Patients are given details of local community based services and opportunities to support their self management moving forward.

Audit and evaluation – the uptake of C/R throughout the UK is variable but it is pleasing that locally we are supporting many more than the national average of around 50% of patients following a cardiac diagnosis. We have a robust audit process in place within D&G and are currently exploring how this may feed into a UK wide dataset to further strengthen the evidence base for C/R interventions.

Coffee and mints

In keeping with C/R tradition, on noteworthy occasions such as retirements and birthdays an after dinner ode to the recipient is dished out along with the coffee. With this in mind….

An ode to NHS D&G staff at Christmas

As Andy Williams famously sang, “it’s the most wonderful time of the year”

Perhaps you’ve spent the last few weeks thinking to where did 2018 disappear?

Now is the time for some fun, rest and reflection, hopefully in equal measure

To celebrate Christmas your own way and with love, kindness and pleasure

Although joyous for many, the festive season can be a sad and difficult time its true

Loneliness, loss, illness, expectation and pressure, maybe feeling more than just a bit blue

Christmas, like a heart attack, doesn’t always look like it does on the big screen

A time of remembrance and contemplation, hopes of what the year may have been

The pace of change in modern healthcare often goes at a rate of knots

Feels like there’s hardly time to do the job, let alone gather your thoughts

We all know too well of the “winter pressures” which don’t seem to relent much year long

Working difficult and unsocial hours, away from our loved ones, where we belong

It’s sometimes hard to remember that we all do a great job and are part of a fab wider team

It’s easy to criticise and get despondent when it doesn’t feel like you’re living the dream

But our local health services are truly amazing and star several thousand of a diverse cast

Staff who are caring, loyal, highly skilled and adaptable, genuine healthcare enthusiasts

So, take some time to enjoy your Christmas soundtrack and whatever is on your menu

The little things in life are often the best, regardless of the venue

Take some time to do “what matters to you” and enjoy some festive cheer

Wishing you and those special to you, health, happiness and peace throughout the New Year.

The cockles of the heart are its ventricles, named by some in Latin as “cochleae cordis”, from “cochlea” (snail), alluding to their shape. The saying means to warm and gratify one’s deepest feelings.

Mairi Small is a Senior Physiotherapist at Cardiac Rehabilitation for NHS Dumfries and Galloway

‘Docere’ by Sonia Cherian

The word ‘Doctor’ is the agentive noun of the Latin verb Docere which means ‘to teach’. The title ‘Doctor’ refers to a person who is recognised to have acquired sufficient knowledge in a subject to be a teacher of that subject. The role of the doctor as a teacher helps educate patients about their condition. A well-informed patient is crucial to the success of any treatment plan. In an era of increasing demands on the healthcare system coupled with  changing patient expectations, the doctor’s role as a teacher has a unique significance.

The supreme court ruling in the Montgomery case (Montgomery v Lanarkshire Health Board, 2015) was a watershed moment from a medicolegal perspective. Mrs Montgomery, a small built diabetic patient had complications during a vaginal delivery which resulted in her son being born with severe disabilities. The case hinged on whether the health board had provided her with all the information which could have helped her make a decision between a normal delivery or a caesarean section. Her obstetrician felt that the risks of shoulder dystocia during normal labour was not significant enough to discuss with her thinking that this information may have resulted in the patient choosing a caesarean section which had its own risks. The supreme court felt that had the risks been explained fully to the patient, she would have opted for a caesarean section and the baby would have been born unharmed. This ruling established that a patient should be told whatever they want to know, not what the doctor thinks they should be told. Mrs Montgomery was awarded a compensation of £5.25 million and the ruling fundamentally changed the law on decision making with the transition from ‘medical paternalism’ to ‘patient autonomy’. The ruling makes it clear that any intervention must be based on a shared decision-making process ensuring the patient is aware of all options and supported in making an informed choice by their healthcare professional.

The General Medical Council (GMC) document on Good medical practice advises to work in partnership with patients:

• You must listen to patients, take account of their views, and respond honestly to their questions.
• You must give patients the information they want or need to know in a way they can understand. You should make sure that arrangements are made, wherever possible, to meet patients’ language and communication needs.
• You must be considerate to those close to the patient and be sensitive and responsive in giving them information and support.

(https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/good-medical-practice/domain-3—communication-partnership-and-teamwork#paragraph-46)

The Realistic Medicine agenda led by the Chief Medical Officer (CMO) of Scotland makes shared decision making and a personalised approach to care its key themes. (https://www.gov.scot/publications/practising-realistic-medicine/)

‘The King’s Fund’ research recommends that patients should be given a chance to take an active role in decisions about their care and treatment by providing the right opportunities, information and support. Services should reflect the needs of patients by meaningfully involving patients and carers in service commissioning, planning, design and improvement. (https://www.kingsfund.org.uk/publications/shared-responsibility-health)

An informed patient can positively contribute to decision making regarding a personalised approach to his or her treatment. This would also mean that patients are more open to share the responsibility of these decisions and be prepared to live with the consequences of their choices thus reducing the risk of complaints and litigation. Patient decisions are not only influenced by medical considerations but also by non-clinical issues which are of relevance to that individual patient. Values, beliefs and life experiences that have a personal significance can influence choices. Our role as clinicians is to support the patient in the decision-making process by providing expert medical advice through a dialogue. Unlike emergency situations where decisions have to be made quickly to save the life or limb of a patient, the vast majority of treatment decisions are taken in primary care or in an elective setting in secondary care. Many conditions have a variety of treatment options, each with its own benefits and risks. In some situations, having ‘no treatment’ is also a reasonable option.

Many patients are well-researched about their condition having read various articles on ‘Google search’. However, for a non-medical lay person to comprehend the vast, often confusing and sometimes contradictory online information can be challenging. This may leave patients with incomplete and out of context information. Hence the information that the patient could assimilate online is quite different from the knowledge that he or she needs to make personalised treatment choices. The clinician has the unique role as a teacher to help transform the information the patient has into knowledge whereby safe personal choices on treatment could be made.

Discussion regarding the various methods of Patient education is a topic on its own and is beyond the scope of this blog. Though innovative ways to deliver succinct information using digital media seems to be the way forward, these would never replace the warmth and compassion of a caring competent clinician who would help patients make the right balanced choices. This would only be possible with the provision of time and resources to improve meaningful information sharing during consultations.

The CMO’s annual report (2016-17) acknowledges that the main barrier to healthcare professionals having more in-depth discussions with patients is the issue of time. “Simply offering the standard treatment or investigation may be quicker, but not necessarily what is in the patients’ individual best interests. It is essential that in order to provide high quality, personalised care clinicians are in a position to make the time to have these important discussions. If we are able to move towards engaging in these conversations as a part of routine practice, it is likely this will in some circumstances save time where patients decide against investigations or treatments that they do not feel are right for them.”

The second Citizens’ Panel Survey (August 2017) revealed that the behaviour/style of the doctor and how busy they are (or are perceived to be) had an impact on patients’ inclination to ask questions. The current legal and regulatory requirements make it the responsibility of the clinician to provide adequate time to the patient so that they are well informed prior to making a decision.  However, the Scottish Public Service Ombudsman (SPSO) has commented in the CMO’s Annual report (2016-17) that this responsibility is not that of the clinician alone. This process would require policy changes within the organisation and a change in culture that encourages and fosters patient centric multi-disciplinary team working.

The GMC guidance, the Supreme court ruling, the concepts of Shared decision-making, Patient centric care and Realistic medicine all point to the pivotal role of patient education  thus highlighting the importance of what it truly means to be a doctor : ‘A Teacher !’

Therefore, let us all remember to ‘teach before we treat !’ and support each other in patient education with the ultimate aim of delivering holistic patient care.

 

Dr. Sonia Cherian is a GP at NHS Dumfries and Galloway as well as a GP Appraiser and CPD Adviser at NHS Education for Scotland

 

 

 

“Undetectable=untransmittable….but only if people are diagnosed and treated” by Gwyneth Jones

As a trainee doctor I moved to Edinburgh in the late 1980’s to start a career in Infectious diseases. The wards were full of people my own age diagnosed with AIDs and given a life expectancy at best of a few years. Many had recurrent, difficult to treat opportunistic infections and suffered progressive decline with weight loss and dreadful skin conditions. Often siblings and close friends were also infected and dying.  As ID specialists we developed skills in breaking bad news; informing and testing terrified partners and supporting patients and families with both a terminal diagnosis and highly stigmatised condition. 

HIV testing was seen as a ‘special test’ and provided with wrap around counselling that benefitted those who tested positive but became a barrier to many clinicians who recognised the importance of testing beyond the initial ‘high risk groups’.  It took considerable campaigning by Lord Norman Fowler in 1987 to persuade Mrs Thatcher that informing the public would save lives.  The PM feared harm would come from discussing risky sexual behaviour but ultimately the hard hitting Tombstone campaign featured on bill boards, cinemas and leaflets to every household. Without effective treatment the only answer to the AIDS epidemic was ‘Don’t die of ignorance’ and protect yourself. The tone and message remained grim.

Thankfully, much has changed but there have been no further government funded health campaigns and many clinicians remain unaware of the transformation in treatment and prognosis for HIV. I am delighted that my F1 colleagues Dr David Gibson, Dr Patsy Fingland and Dr Chryssa Neo have been exploring how we can better inform colleagues about the need for increased HIV testing and ensure that Dumfries and Galloway plays it part in reaching the end of the HIV epidemic.

December 1^st 2018 celebrated the 30^th Anniversary of World AIDS day. People diagnosed early with HIV can now expect to remain healthy with near, normal life expectancy. Treatment options include single tablet regimens of combination antiretrovirals started at diagnosis regardless of CD4+ cell count. Damage to the immune system is avoided and side effects are much reduced.  But it has been the findings of the PARTNER studies that provide an extra piece in the quest to eradicate HIV. Since patients receiving treatment that had undetectable viral load showed no ongoing transmission. UNDETCABLE=UNTRANSMITTABLE.

The challenge now is to ensure all those infected are tested and know their HIV status. This worldwide ambition is encompassed in the UNAIDS 90-90-90 campaign……

So how can we improve? 

We want everyone to feel that they can prompt HIV testing. Doctors in training may feel uncertain as they rotate around new wards but we hope to encourage nursing, pharmacy and dietetic staff to recognise indicator conditions and suggest HIV testing. Our poster aims to increase awareness and we will follow up our recent survey with more ‘bite size’ HIV education.

The message is simple. You don’t need to worry about asking ‘risky questions’. You simply need to offer a test and very few patients decline.

HIV testing saves lives. 

Gwyneth Jones is a Consultant in Infectious Diseases and General Medicine and was helped in the writing of this blog by David Gibson, Patsy Finland and Chryssa Neo, all Foundation Year One Doctors currently working at NHS Dumfries and Galloway