9 August 2019

Taking a bit of time can be its own reward

General Practice

Time is a funny thing in general practice.

Just as the length of a minute depends on what side of the toilet door you’re on, the length of a consult seems to depend on whether you’re waiting for yours or within one with your GP.

General practitioners have often written and spoken about how challenging it is to fit in medical issues within the allotted 15 minutes. Some do it well and some naturally tend to have longer consults.

All thoughts and ideas about consult time go out the window when you’re looking after patients from a group home. To clarify, these are patients who live in supported or semi-supported residences and have an intellectual and/or physical disability.

I am fortunate enough to be one of the doctors at my practice looking after group home patients in our local area, and I say fortunate because it is truly rewarding medicine. When it works.

“Doctor, I’m this patient’s usual carer and he has been having far too many falls recently and his behaviour seems really off.” A full workup revealed a stroke of indeterminate age in the frontal lobe.

“Here’s a chart from the night staff, they’ve been noticing the client getting up to go to the toilet several times at night and waking up the other residents.” A urine dipstick, after much cajoling and bribing, confirms a UTI.

It is rewarding in other ways, too. When a patient recognises my face, smiles and waves enthusiastically every time I walk into the waiting room. Even if it isn’t to call their name or if they’re seeing another doctor. One of my patients with progressive muscular atrophy showing me how she’s had her wheelchair “pimp’d out”. (God I’m getting old)

But as I said, time takes on a whole new dimension when you’re managing group-home patients.

It is well documented in multiple studies that these patients suffer a disproportionate burden of chronic metabolic conditions. Quite a few of them are on multiple medications and most of these are often antipsychotics or anti-epileptic medications at high doses.

What makes all this trickier is that it can often be very hard for patients from group homes to verbalise what they are feeling.

Any history I gather is usually from staff observation and this can vary wildly. It is very difficult to ascertain the story from what is an often under-trained, under-supported, casual and transient workforce. Often, they don’t know the patient well enough themselves and almost always don’t really know why they have presented, except that the GP appointment was listed in the day’s program.

The staff can’t always be blamed though. While discussing their workload with them once, a worker told me that she gets approximately 8-10 minutes per resident to get them bathed, cleaned dried and dressed for breakfast.

This is similar to what workers in the aged-care sector face. In the group home, throw in challenging behaviour, refusal to take morning medications and toileting needs, the burden on the staff is often massive.

Workers who get to know their clients are national treasures. Not only do they recognise the subtle changes in their clients’ behaviours, which is absolute gold for me as a GP, but they are often able to practise and implement behavioural strategies that work so much better than medications to control “behaviour”.

I had a patient once, who was brought in by a casual carer and a sheet that said, “client has not eaten anything all day”. On further investigation and after ringing the patient’s usual carer at the home, I was able to find out that the patient hadn’t had lunch because they hated kebabs.

Looking after group-home patients can take a significant toll. What seems like a straightforward investigation in most patients, such as bloods or imaging, can be extremely difficult for a variety of reasons. One must consider the issue of consent but also, quite a few group-home patients find it very hard to follow instructions for imaging or are needle-phobic.

I smile inwardly when the radiologist writes: “This was a technically difficult study…”

Often, I must decide on whether my provisional diagnosis is serious enough to warrant these investigations being carried out under sedation at the local hospital.

I have made a blanket rule of booking group-home patients for long consults. Inevitably there are multiple issues to consider. I also book 40-minute appointments for care plans and annual health assessments, because these are absolutely essential in maintaining some semblance of preventative care in these patients.

One of the other things I have started doing is trying to wean down a lot of the medications charted for controlling “behaviour” if there is no clear indication. Finding a behavioural therapist with some experience in managing patients with disabilities is key, and often, when staff are empowered to make these changes in conjunction with the pharmacist, they take ownership of the patient and celebrate if their patient’s LFTs or urine ACRs improve.

Of course, one could go on about the health inequities, the poorly funded residential and disability system and the abuse of patients that sometimes occurs in group homes.

But as with all patients, when it comes to being their health advocate as their GP, there is a lot that one can achieve … if we spend enough time with them.

Dr Aajuli Shukla is a general practitioner in Blacktown, Sydney, and GP Editor of The Medical Republic