Consultation Skills for Chronic Communicable & Non-Communicable Diseases.

Most patients with chronic illnesses are usually previously diagnosed, they are likely to know their own diagnoses, and most times, they are already on some forms of regular medication.

While most chronic illnesses are noncommunicable in nature, it is noteworthy that some infectious diseases run chronic courses.

Common examples of chronic illnesses:

Non-Communicable Diseases

Hypertension, diabetes mellitus, thyroid diseases, cardiac failure, ischemic heart diseases (such as myocardial infarction – that is heart attack, and unstable angina), anaemias, asthma, COPD, osteoarthritis, rheumatoid, Cancers, some central nervous system diseases such as epilepsy and Parkinson’s disease, hematological disorders such as sickle cell disease, deep venous thrombosis, etcetera.

Communicable (i.e. Infectious) Diseases

While most communicable (or infectious) diseases are acute in nature, some are chronic. Examples are: human immunodeficiency virus HIV/AIDS, tuberculosis, some meningitis such as tuberculous and cryptococcal meningitis, etcetera.

During consultation with these patients, you need to consider the following “Cs” in order to offer a more holistic approach to their management.

1. Complaint: How may I help you today?

You need to understand why the patient has come for consultation that day.

Most of the time, it’s their routine follow up date. And they do not have any (new) complaint.

However, some patients keep their complaints until their follow up date to discuss with their doctors. Some others have acute complaints, a worsening of their symptoms, and so forth.

All these must be addressed during the consultation.

2. Compliance/Adherence: Are you taking your meds?

Your patient is already on a chronic drug regimen, so, you need to know if they are taking their treatment.

Other questions that are relevant include the following:

• How are they taking their treatment? Some patients reduce their dosage or frequency.
• How do they remember to take their pills? – e.g. by use of cellphone alarms, pill boxes, diaries, meal times .
• When was the last time they took their medication? For example, their current raised bllod pressure might be because they had not taken their meds this morning, and not because the meds are not working.
• Do they sometimes forget to.take your medications?
• How many days of the week do they forget to take their pills on the average?
• Are they having problems taking their medications – maybe it too big, there are too many pills, or they are having side effects.

There is no point prescribing the same medications if your patient is having problems taking them. Sometimes, you increase dosages when your patient is not even taking the current dose.

You need to ascertain adherence to medication at every consultation.

It is noteworthy, that adherence to lifestyle modifications is part of what youre looking for.

3. Control: Are your patient controlled on their current medications?

Each disease entity has its own indices of control.

• For asthma, you need to ask about the control, frequency, and severity of symptoms.
• Blooood pressure measurement for hypertension,
• random glucose and HBA1c for diabetes,
• number of fits per month for epilepsy,
• pain and limitation of activity in osteoarthritis, etcetera.

The findings from the control indices will inform the decision whether to keep patient on same regimen, to increase or reduce dosage, to add more medication or remove, and so foeth.

4. Complications and other idiosyncrasies: Are your pills right for you?

You need to find out from your patient if they are comfortable with their medications.

If you patient think paracetamol is giving them headache, they will never take it, no matter how much you try to convince them.

Likewise, some patients prefer a particular brand of the same medications to the other. Or they prefer the yellow box to the black box, or single strength to double strength dosing, capsule rather than tablets, and so forth.

However, beyond these idiosyncrasies, there are real problems, such as documented complications, disease progression, and end organ damage.

And it is your responsibility to actively prempt and prevent these complications and also prevent further damage.

Remember, your ethical responsibility as a doctor is to do good (beneficence), and do no harm (non-maleficence).

So, your routine monitoring for end organ damage is vital.

For example, regular blood workup – hemoglobin, urea and creatinine, viral load, liver function, urinalysis, fundoscopy, foot examination, etcetera depending on the specific conditions, must be taken very seriously.

5. Co-morbidities: Are there any other problems that you want me to know about?

Ask your patients if they have any other comorbid conditions, and very importantly, screen them for common conditions.

Encourage your patient to come for regular checks, such as blood pressure, blood sugar, and cholesterol checks, annual blood workup, HIV testing, mammograms, pap smears, and so forth.

Conclusion

By taking these different components of care into consideration, you will be able to adeqautely assist your chronic patients every time they consult.

It will improve your doctor-patient relationship because they know you will address their problems.

It is unacceptable for your chronic patient to deteriorate under your watch particularly when it is avoidable.

On the average, as a doctor, you should be able to spend between 8 and 15 minutes with your patient during a consultation. (Evidence based).

Asking simple questions during such contacts in each consultation will go a long way in making a difference in your patients’ lives and in improving the quality of their health.