Bayesian decision making in primary care – or how to stop people dying of chicken pox Trisha Greenhalgh Professor of Primary Health Care UCL Before we start: What is primary health care? Hospital medicine “Distinguishing the clear message of the disease from the interfering noise of the patient as a person.” Marshall Marinker ‘The mythology of Hilda Thompson’ In Greenhalgh T and Hurwitz H (eds) ‘Narrative Based Medicine’ London: BMJ Books, 1998 Primary health care “In secondary care diseases stay, but patients come and go, whereas in primary care patients stay but diseases come and go." Iona Heath ‘The mystery of general practice’ London: Nuffield Provincial Hospitals Trust, 1995 Primary health care “First-contact care, delivered by generalists, dependent on teamwork, which is accessible, comprehensive, co-ordinated, population-based, and activated by patient choice.” Pat Gordon and Diane Plamping ‘Extending Primary Care’ Oxford: Radcliffe, 1996 Primary health care “Doing simple things well, for large numbers of people, few of whom feel ill.” Julian Tudor Hart ‘A new kind of doctor’ London: Merlin Press, 1998 Case history A patient with query chicken pox A patient with chicken pox It was Saturday morning I was on call from 8.30 am I got a call from one of my partners, Dr B, at 5.45 am He was on holiday 200 miles away but had been called on his mobile phone by Health Call One of his patients had rung Health Call and demanded a visit by Dr B No other doctor would A patient with chicken pox The family had a child with chicken pox She had been seen the day before by another partner, Dr R, who has 24 years’ experience in general practice and is also a clinical assistant in dermatology She had said it was “definitely chicken pox” and prescribed fluids, analgesia and calamine A patient with chicken pox The child had apparently deteriorated and the parents were worried They had decided that only Dr B would know what to Dr B (who was many miles away) asked me to go round immediately and examine the child I was not yet on call and keen to go for my early morning swim before surgery What should my next move be? ACT TWO (3 weeks later) TG Hello How’ve you been? CM [she looks dramatically better, in a clean, pressed blouse and a hint of lipstick] Better Definitely better […] I’m still low – but not low low Those tablets are better I can some normal things Like I cleaned the windows yesterday TG Good grief You can come and clean mine if you’re feeling like that! CM [laughs] But today… today isn’t so good TG It will come and go CM Yes, I’m realising that TG What about work? CM My manager came to see me at home She’s been really good They’re transferring me to another branch – down at X TG Oh, that tiny one on the corner? CM Mm There’s only seven staff They keep saying it should be closed as there’s not enough business TG Well that’ll suit you fine for a bit, won’t it? CM Yeah, I’m ready to give it a go TG And how’s the counselling? CM [suddenly cries] Oh that The young lass I did two sessions, but it seemed to upset me more TG It often does CM She kept wanting me to talk about the worst things So I cancelled the last time TG Oh dear What you want to about that? CM Well I’m going back to work now aren’t I? TG And the exercise? CM I did ring them up I’m seeing your man this afternoon actually [Gets up and looks in mirror] I hope he’s going to tell me how to lose this weight TG I’m sure if you put that as one of your goals he’ll suggest something for it CM And you did say there would be other people there, doctor TG Yes, there will be loads of people there for weight loss That’s the commonest thing people get referred for CM What, as bad as me? [indicating her tummy] TG Oh, worse And other problems – diabetes, blood pressure, that sort of thing And some people will be there for depression too CM I’m so looking forward to meeting some new people You see, all the friends I’ve got were sort of ‘our’ friends, and I want to get some that are just ‘my’ friends TG Okay then, so you want me to sign you back to work CM Yes, I was planning to go back Monday TG [writes certificate] Fine But I’d like to see you again in a month to see how you’re getting on CM Can I weigh myself on those scales? TG Yes of course We can check it again in a month’s time CM I am nervous, you know doctor TG It’s a big step But you said you’re ready to have a go CM [takes deep breath as she is leaving] Mm Bye doctor ‘Textbook’ medical consultation • • • • • • Take a history Examine the patient Order investigations Establish a differential diagnosis Prescribe treatment Refer if indicated The narrative approach • • • • Takes a holistic view of the problem Sees illness as part of a life story Places the patient as narrator [subject] Uses the storytelling (and listening) as part of the treatment • The doctor’s role is partly to suggest alternative ‘storylines’ A STORYLINE HYPOTHESIS l a c si y h y p r od e H b Her work Her marital relationship Her daughter and grandson He r fr ien ds ACT ONE: A fragmented, inconsistent, unfinished, unhappy story ‘Dear Trudy’ letter STORYLINE OPTION: Psychiatric illness Her leisure activities ‘Dear Ali’ letter STORYLINE OPTION: Shaping up and meeting people ACT TWO: The ‘back to work’ plot The referral as a ‘twist in the plot’ • Summarises the story so far • Focuses on some aspects at the expense of others • Attributes causality to events • Interprets behaviour and assigns motives HENCE • Changes the direction of the story Dear Trudy Thanks for seeing this 54 year old lady with depression She has recently been through a divorce and is losing the family home She has had some suicidal ideation but denies concrete plans She works as a bank clerk but is currently off sick She has one daughter who lives locally but with whom she has little contact, and a four year old grandson She has been prescribed Prozac but I wonder if she is taking it Thanks for seeing her with a view to counselling I have also referred her to Prescription for Exercise Dear Ali Thanks for seeing this 54 year old lady with depression and mild obesity She went through a divorce recently and now feels the time has come to work on her physical shape and meet new people She has no physical contra-indications except the usual low cardiorespiratory fitness She is taking HRT and an antidepressant Her blood pressure is normal She is off sick right now but when she returns to work she will need to fit the sessions in around her flexitime I’m grateful to you for organising this Case 2: Summary Conventional medicine draws a linear and rational sequence of history-taking, examination, investigation, provisional diagnosis, referral and treatment An alternative view is to see the illness as an unfinished story A referral can be a crucial ‘twist in the plot’, and may offer the patient a range of storyline options Thank you for your attention Handouts available from Marcia Rigby m.rigby@pcps.ucl.ac.uk