Article by Holly Lawrence
We all have an innate desire to have a partner—a person who understands who we are and what is important to us—during difficult times in our lives. Patients who suffer with a chronic disease need a primary care physician who partners with them in co-managing their care and understanding their priorities for a good quality of life.
Unfortunately, research shows that patients and their physicians are not always on the same page when it comes to priorities.
An observational study, published in 2019 by the Annals of Family Medicine and conducted by researchers in Paris, found discrepancies in the level of agreement between patients and their primary care physician on prioritizing the chronic conditions affecting the patient.
As explained in a news release, the researchers conducted surveys from April to May 2017 in which they listed 124 chronic conditions. Participants were asked to report all of the patient’s chronic conditions on the list, and rank up to three top priority conditions. Of the 153 patient-physician pairs that wrote a priority list, 29% of the patients’ first priorities did not appear anywhere on their physician’s list, and 12% of the pairs had no matching priority conditions.
Dr. Stéphanie Sidorkiewicz, a general practitioner in Paris and a researcher at Paris Descartes University who led the study said in an email that the findings align with similar studies in other countries, focusing on patients with chronic conditions.
Challenges of Treating Multimorbidity
Numerous studies indicate that multimorbidity—multiple chronic conditions—has become a normal occurrence in patients, including those patients with COPD. This presents a challenge to primary care physicians, and serious negative, even fatal consequences to patients suffering with two or more physical and mental health conditions.
But the study in France revealed that patients and their physicians were not on the same page about the patient’s top three priority conditions. Noting a previous cross-sectional study that found 23% of patients had two or more chronic conditions, Sidorkiewicz and her colleagues wrote: “From the patient’s perspective, having a chronic condition requires effective self-care and participation. From the GP’s perspective, the inability to identify some conditions (eg, chronic anxiety disorder), symptomatic concerns (eg, sleeping disorder), or behaviors (eg, tobacco use) may lead to inadequate management and suboptimal counseling.”
“Organ failure with deteriorated everyday functions, and fear of getting worse without being able to self-manage or control the situation, are typical sources of lowered quality of life in a patient with an advanced disease,” said Dr. Hanna Sandelowsky, a general practitioner in Stockholm and researcher at Karolinska Institutet Medical University.
Sandelowsky, who currently studies COPD, management of multimorbidity, and GP continuing medical education, explained: “My research indicates that patients with early (or mild) COPD have equally high, if not higher, needs of more information than those with more advanced disease. A common comorbidity of COPD is anxiety/depression, and low levels of knowledge about self-management are known to increase the level of anxiety and depression in patients with COPD.”
Patient and physician communication, education and agreement are essential in treating conditions and maintaining quality of life.
Managing COPD as a Team Effort
Primary care physicians need to develop a relationship with the COPD patients and learn what is troublesome for the patient in everyday life, Sandelowsky suggested. “The most important thing for GPs to remember is that only doing the classic “doctor’s job,” i.e. prescribing medications, will not bring them closer to understanding or helping [their] COPD patient.”
Establishing rapport with the patient, Sandelowsky said, may require more than strictly medical functions. “You need to build trust and let it take time, probably several appointments,” said Sandelowsky. “This is why no doctor can manage COPD on their own. Instead, the care is based on teamwork, or, interprofessional cooperation, between the GP, nurse, physiotherapist, nutritionist, occupational therapist, counselor—and not to forget, the family of the patient.”
Telehealth professionals may also play an important role as members of this team.
“It is very difficult to assess all of a patient’s needs and goals during a 15-minute office visit,” said Todd Allen, a telehealth RN and case manager with Four Seasons, a nonprofit hospice and palliative care provider that serves patients in rural Appalachia. Allen explained that “physicians tend to focus on treating the COPD progression, and miss the quality of life issues such as dyspnea, anxiety, depression and loss of independence.”
Patient-Centered Care and Communication
Allen, who works with more than 150 rural palliative care patients with limited access to their primary care physicians or major hospitals said, “Open lines of communication such as telehealth really help to extend the communication, and fill the gap between office visits. When people communicate it is more likely that problem will be identified and resolved.”
Allen acknowledged that the home visits allow telehealth providers to be better positioned than primary care or specialists in learning the patient’s goals and priorities. “Because we keep an open line of communication with patients and caregivers through telehealth,” Allen said, “the patient no longer feels alone, worries about getting medical advice, refills on meds and assistance with acute symptoms. They know we are here for them and are just a secure text message away.” Allen said he believes that patients and caregivers benefit from being heard, and have trust that their concerns will be quickly addressed.
Allen explained that primary care physicians are not asking the questions to get to understand their patient’s issues and chronic conditions. “[Physicians] are focused on their electronic health records. That’s how they get paid. They’re going through a bulleted list of items they have to check in order to get paid. But they are not asking the right questions.”
Allen shared one of his favorite questions on his patient telehealth application: Tell me about something you wanted to do today, but couldn’t. “I get all kinds of answers, like ‘I couldn’t go outside today because it was raining.’ If you have COPD and you have a low-pressure system, you can’t go outside. You can’t breathe,” Allen said.
“‘I couldn’t go to the mailbox,’ is one I’ve seen a number of times,” Allen said. “Going to the mailbox means independence for a COPD patient. To be able to walk that distance for a COPD patient, is, I mean…think about that. What if you can’t go to your own mailbox?”
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