LETTER
“Computer–patient–physician” relationship To the Editor: The interposition of the computer screen between patient and physician as a tangible ‘third party’ in the encounter may turn into a double-edged sword. On one hand, it is an indispensable tool for scrutinising the full patient’s records and test results as well as for communication, test-ordering, prescribing, reminders, patient instruction and reducing medical errors – not to mention its role in clinical decision support and consulting databases. On the other hand, patients report and video-based studies confirm that physicians are now often immersed in their screens, gazing, keyboarding and hardly able to separate, or connect to them (1,2). This applies not only to primary care since increasing numbers of hospitals are using portable computers and electronic medical records on ward rounds. The increasing dominance of the computer threatens the patient–provider relationship (PPR) – a core attribute of a successful clinical encounter (3). To reconcile the distractions of the quintessential screen with the crucial delivery of personal, patient-centred and empathic care (4), the following ‘five Commandments’ of PPR in the computer era are suggested: ● Go over the patient’s chart before the patient enters your office or before going to the bedside. Have command of the essentials. ● Once you have addressed the patient, maintain eye contact and utter concentration. Willfully avoid distractions such as checking on e-mails or calls. Never skip examination of the patient. ● If you need to consult a database, textbook, or guideline – do so at once and let the patient know. Most patients will appreciate your caution and thoroughness rather than despise your lack of knowledge (5).
● Leave all documentation and necessary print-outs to the end of the encounter. ● Always finish the encounter by leaving the computer alone and personally addressing the patient, raising issues of health literacy, shared decision-making and summarising the current encounter and future goals. Other suggestions have been made to reconcile the effects of provider immersion in the computer at the expense of the patient (3,6). They include training to enhance baseline communication skills; improved positioning of the screen and provider in the room; ‘blind’ typing; and sharing the computer screen with the patient. The patient–physician relationship remains fundamental to the provision of effective healthcare and healing. It is much dependent on communication, including non-verbal behaviour essential for communicating attitudes, emotions and affect. Thus, gaze and eye contact are strongly associated with patients’ perceptions of clinician empathy and interest in the patient and with patients’ satisfaction and trust (3,7) which beget adherence and better ‘hard’ health outcomes (4). Increased awareness of the potential disruptive effect of excessive attention to the computer during the encounter and following the five simple techniques suggested may contribute to an unhindered physician–patient relationship and to the delivery of improved, patient-centred care, a major IOM goal. Educating ourselves on techniques that allow less absorption in the screen and better personal contact needs wider dissemination. Patient satisfaction can be evaluated with or without the intervention suggested above and is likely to substantially increase (8), begetting better patient attachment and a myriad of healthcare benefits and improved outcomes.
A. Schattner, Department of Public Health, Ethox Centre, University of Oxford, Oxford, UK Tel.: +44 7585891525 Fax: +44 1865287884 E-mail: [email protected]
References 1 Margalit RS, Roter D, Dunevant MA et al. Electronic medical record use and physician-patient communication: an observational study of Israeli primary care encounters. Patient Educ Couns 2006; 61: 134–41. 2 Frankel R, Altschuler A, George S et al. Effects of exam-room computing on patient-clinician communication. J Gen Intern Med 2005; 20: 677–82. 3 Ventres WB, Frankel RM. Patient-centered care and electronic health records: it’s still about the relationship. Fam Med 2010; 42: 364–6. 4 Schattner A. The silent dimension. Expressing humanism in each medical encounter. Arch Intern Med 2009; 169: 1095–9. 5 Kahane S, Stutz E, Aliarzadeh B. Must we appear all knowing? Patients’ and family physicians’ perspectives on information seeking during consultations. Can Fam Physician 2011; 57: e228–36. 6 Duke P, Frankel RM, Reis S. How to integrate the electronic health record and patient-centered communication into the medicalo visit: a skills-based approach. Teach Learn Med 2013; 25: 358–65. 7 Montague E, Xu J, Asan O et al. Modeling eye gaze patterns in clinician-patient interaction with lag sequential analysis. Hum Factors 2011; 53: 502–16. 8 Ciechanowski P, Katon WJ. The interpersonal experience of health care through the eyes of patients with diabetes. Soc Sci Med 2006; 63: 3067–79.
Disclosure None identified. doi: 10.1111/ijcp.12424
LETTER
Can hypoglycaemic medications be withdrawn in older people with type 2 diabetes? To the Editor: Diabetes in older people is associated with high comorbidity burden and geriatric syndromes such as cognitive dysfunction, physical disability, malnutrition, falls, fractures and incontinence. Ageing is also associated with a marked decrease in body weight and food
790
intake (1). Therefore, tight glycaemic control may not be appropriate for some older patients who are frail and subject to multiple comorbidities because of increased risk of hypoglycaemia (2). In such patients, it may be appropriate to withdraw the hypoglycaemic medications. This report describes
whether hypoglycaemic medications can be withdrawn in a select group of older patients (≥ 75 years) with diabetes attending an outpatient clinic and explore the characteristics of these patients. A total of eight patients had their hypoglycaemic medications completely withdrawn.
ª 2014 John Wiley & Sons Ltd Int J Clin Pract, June 2014, 68, 6, 790–792. doi: 10.1111/ijcp.12424
Letters
Table 1 Baseline characteristics of all
patients (n = 8)* Age (years) Mean (SD) Range Sex Female (%) Duration of diabetes Mean (SD) Range Duration of insulin therapy (year) Mean (SD) Range Insulin daily dose (units) Mean (SD) Range Comorbidities (%) Vascular disease Hypertension Dementia COPD Falls Anaemia Partially sighted Leg ulcers Chronic lymphatic leukaemia Social factors (%) Living at home Care home resident Permanent carer Mobile with aids Assistance with ADL
86.5 (3.2) 80–90 6 (75) 17.8 (5.9) 8–25 6 (2.6) 4–12 25 (12) 18-48 7 5 4 3 2 2 2 1 1
(88) (63) (50) (38) (25) (25) (25) (12.5) (12.5)
5 3 2 5 5
(63) (37) (25) (63) (63)
SD, standard deviation; COPD, chronic obstructive pulmonary disease; ADL, activities of daily living. *Characteristics at the point of complete hypoglycaemic medications withdrawal.
ª 2014 John Wiley & Sons Ltd Int J Clin Pract, June 2014, 68, 6, 790–792
12 Patient-1 Patient-2 Patient-3 Patient-4 Patient-5 Patient-6 Patient-7 Patient-8
10 8
HbA1c (%)
Baseline characteristics at the point of complete medications withdrawal are summarised in Table 1. Seven of the eight patients were on insulin therapy (four patients were on insulin in combination with oral hypoglycaemic medications and three patients were on insulin alone). One patient was only on oral hypoglycaemic medication. Tight glycaemic control (HbA1c ≤ 6%) was the main reason for medication withdrawal in two patients while recurrent episodes of hypoglycaemia were the main reason in the other six patients. Hypoglycaemic medications were completely withdrawn over a 3–6 months and the follow-up was 1 year period after complete withdrawal. There was no deterioration of glycaemic control over the follow-up period (Figure 1). There was no significant difference between the mean (SD) of HbA1c at the point of hypoglycaemic medications withdrawal and at 1 year of follow-up, 6.2% (0.8)
791
6 4 2 –6
–3
0
0 3 6 Duration (months)
9
12
Figure 1 HbA1c (%) values for the eight patients 6 months before and up to 1 year after complete withdrawal of hypoglycaemic medications
and 6.5% (0.7), difference of 0.3 [95% confidence interval (CI) 1.1 to 0.5, p = 0.4], respectively. Liver and renal functions were similar at the point of medication withdrawal compared with their levels at the point of introducing diabetes treatment. On the other hand, demographic characteristics of patients have changed significantly between both points with increasing the mean level of comorbidities (4.1 vs. 6.8, difference 2.7, 95% CI 1.3–3.9, p = 0.002), number of medications (6.4 vs. 10.1, difference 3.7, 95% CI 1.4–6.1, p = 0.01) and decreasing weight (88.0 vs. 75.4 kg, difference 12.6, 95% CI 5.9–19.3, p = 0.003). Successful withdrawal or reduction in hypoglycaemic medications has been shown previously in a cohort of frail nursing home older patients, mean (SD) age 84.4 (6.8) years with diabetes (3). The main characteristics of our cohort of patients at the point of hypoglycaemic medications withdrawal were the significant weight loss, increased comorbidities and polypharmacy which are all risk factors for hypoglycaemia. It is likely that this cohort of patients have become very frail with increasing weight loss leading to recurrent hypoglycaemia. It is known that diabetes mellitus increases the risk of lean body mass loss or sarcopenia than in persons without diabetes increasing their risk of developing frailty (4). At the point of hypoglycaemic medications withdrawal, five (63%) patients needed help with activities of daily living and three (37%) were admitted to care homes. It has been previously shown that markers of underlying frailty such as older age, use of multiple medications and frequent hospitalisations are associated with increased risk of hypoglycaemia (5). At the point of hypoglycaemic medications withdrawal, four (50%) patients were already diagnosed with dementia. The risk of hypoglycaemia has also been shown to be higher in patients with dementia or cognitive dysfunction (6). In summary, our cohort of patients were very old, have multiple comorbidities including dementia and polypharmacy that contributed to frailty
and frequent hypoglycaemia. Therefore, hypoglycaemic medications withdrawal in such patients including insulin appeared to be safe and might decrease the risk of hypoglycaemia with its serious consequences (7). Although current guidelines (8) suggest less tight glycaemic control in frail older people with diabetes, it does not explicitly recommend complete medication withdrawal which we believe it should be considered in certain patients. A. H. Abdelhafiz,1 P. Chakravorty,1 S. Gupta,1 A. Haque,1 A. J. Sinclair,2 1 Department of Elderly Medicine, Rotherham General Hospital, Rotherham, UK 2 Bedfordshire & Hertfordshire Postgraduate Medical School University of Luton, Luton Bedfordshire, UK E-mail: [email protected]
References 1 Wakimoto P, Block G. Dietary intake, dietary patterns and changes with age: an epidemiological perspective. J Gerontol A Biol Sci Med Sci 2001; 56: 65–80. 2 Abdelhafiz AH, Sinclair AJ. Hypoglycaemia in residential care homes. Br J Gen Pract 2009; 59: 49– 50. 3 Sjoblom P, Tengblad A, Lofgren UB et al. Can diabetes medication be reduced in elderly patients? An observational study of diabetes drug withdrawal in nursing home patients with tight glycaemic control. Diab Res Clin Pract 2008; 82: 197–202. 4 Lee JSW, Auyeung TW, Leung J, Kwok T, Leung PC, Woo J. The effect of diabetes mellitus on age-associated lean mass loss in 3153 older adults. Diabet Med 2010; 27: 1366–71. 5 Shorr RI, Ray WA, Daugherty JR, Griffin MR. Incidence and risk factors for serious hypoglycemia in older persons using insulin or sulfonylureas. Arch Intern Med 1997; 157: 1681–6. 6 Feil DG, Rajan M, Soroka O, Tseng CL, Miller DR, Pogach LM. Risk of hypoglycemia in older veterans with dementia and cognitive impairment: implications for practice and policy. J Am Geriatr Soc 2011; 59: 2263–72.
792
Letters
7 Goto A, Arah OA, Goto M et al. Severe hypoglycaemia and cardiovascular disease: systematic review and meta-analysis with bias analysis. BMJ 2013; 347: f4533. doi:10.1136/bmj.f4533.
8 American Diabetes Association. Executive summary: standards of medical care in diabetes-2014. Diabetes Care 2010; 37: S14–80.
Disclosure None. doi: 10.1111/ijcp.12455
ª 2014 John Wiley & Sons Ltd Int J Clin Pract, June 2014, 68, 6, 790–792
“Computer–patient–physician” relationship To the Editor: The interposition of the computer screen between patient and physician as a tangible ‘third party’ in the encounter may turn into a double-edged sword. On one hand, it is an indispensable tool for scrutinising the full patient’s records and test results as well as for communication, test-ordering, prescribing, reminders, patient instruction and reducing medical errors – not to mention its role in clinical decision support and consulting databases. On the other hand, patients report and video-based studies confirm that physicians are now often immersed in their screens, gazing, keyboarding and hardly able to separate, or connect to them (1,2). This applies not only to primary care since increasing numbers of hospitals are using portable computers and electronic medical records on ward rounds. The increasing dominance of the computer threatens the patient–provider relationship (PPR) – a core attribute of a successful clinical encounter (3). To reconcile the distractions of the quintessential screen with the crucial delivery of personal, patient-centred and empathic care (4), the following ‘five Commandments’ of PPR in the computer era are suggested: ● Go over the patient’s chart before the patient enters your office or before going to the bedside. Have command of the essentials. ● Once you have addressed the patient, maintain eye contact and utter concentration. Willfully avoid distractions such as checking on e-mails or calls. Never skip examination of the patient. ● If you need to consult a database, textbook, or guideline – do so at once and let the patient know. Most patients will appreciate your caution and thoroughness rather than despise your lack of knowledge (5).
● Leave all documentation and necessary print-outs to the end of the encounter. ● Always finish the encounter by leaving the computer alone and personally addressing the patient, raising issues of health literacy, shared decision-making and summarising the current encounter and future goals. Other suggestions have been made to reconcile the effects of provider immersion in the computer at the expense of the patient (3,6). They include training to enhance baseline communication skills; improved positioning of the screen and provider in the room; ‘blind’ typing; and sharing the computer screen with the patient. The patient–physician relationship remains fundamental to the provision of effective healthcare and healing. It is much dependent on communication, including non-verbal behaviour essential for communicating attitudes, emotions and affect. Thus, gaze and eye contact are strongly associated with patients’ perceptions of clinician empathy and interest in the patient and with patients’ satisfaction and trust (3,7) which beget adherence and better ‘hard’ health outcomes (4). Increased awareness of the potential disruptive effect of excessive attention to the computer during the encounter and following the five simple techniques suggested may contribute to an unhindered physician–patient relationship and to the delivery of improved, patient-centred care, a major IOM goal. Educating ourselves on techniques that allow less absorption in the screen and better personal contact needs wider dissemination. Patient satisfaction can be evaluated with or without the intervention suggested above and is likely to substantially increase (8), begetting better patient attachment and a myriad of healthcare benefits and improved outcomes.
A. Schattner, Department of Public Health, Ethox Centre, University of Oxford, Oxford, UK Tel.: +44 7585891525 Fax: +44 1865287884 E-mail: [email protected]
References 1 Margalit RS, Roter D, Dunevant MA et al. Electronic medical record use and physician-patient communication: an observational study of Israeli primary care encounters. Patient Educ Couns 2006; 61: 134–41. 2 Frankel R, Altschuler A, George S et al. Effects of exam-room computing on patient-clinician communication. J Gen Intern Med 2005; 20: 677–82. 3 Ventres WB, Frankel RM. Patient-centered care and electronic health records: it’s still about the relationship. Fam Med 2010; 42: 364–6. 4 Schattner A. The silent dimension. Expressing humanism in each medical encounter. Arch Intern Med 2009; 169: 1095–9. 5 Kahane S, Stutz E, Aliarzadeh B. Must we appear all knowing? Patients’ and family physicians’ perspectives on information seeking during consultations. Can Fam Physician 2011; 57: e228–36. 6 Duke P, Frankel RM, Reis S. How to integrate the electronic health record and patient-centered communication into the medicalo visit: a skills-based approach. Teach Learn Med 2013; 25: 358–65. 7 Montague E, Xu J, Asan O et al. Modeling eye gaze patterns in clinician-patient interaction with lag sequential analysis. Hum Factors 2011; 53: 502–16. 8 Ciechanowski P, Katon WJ. The interpersonal experience of health care through the eyes of patients with diabetes. Soc Sci Med 2006; 63: 3067–79.
Disclosure None identified. doi: 10.1111/ijcp.12424
LETTER
Can hypoglycaemic medications be withdrawn in older people with type 2 diabetes? To the Editor: Diabetes in older people is associated with high comorbidity burden and geriatric syndromes such as cognitive dysfunction, physical disability, malnutrition, falls, fractures and incontinence. Ageing is also associated with a marked decrease in body weight and food
790
intake (1). Therefore, tight glycaemic control may not be appropriate for some older patients who are frail and subject to multiple comorbidities because of increased risk of hypoglycaemia (2). In such patients, it may be appropriate to withdraw the hypoglycaemic medications. This report describes
whether hypoglycaemic medications can be withdrawn in a select group of older patients (≥ 75 years) with diabetes attending an outpatient clinic and explore the characteristics of these patients. A total of eight patients had their hypoglycaemic medications completely withdrawn.
ª 2014 John Wiley & Sons Ltd Int J Clin Pract, June 2014, 68, 6, 790–792. doi: 10.1111/ijcp.12424
Letters
Table 1 Baseline characteristics of all
patients (n = 8)* Age (years) Mean (SD) Range Sex Female (%) Duration of diabetes Mean (SD) Range Duration of insulin therapy (year) Mean (SD) Range Insulin daily dose (units) Mean (SD) Range Comorbidities (%) Vascular disease Hypertension Dementia COPD Falls Anaemia Partially sighted Leg ulcers Chronic lymphatic leukaemia Social factors (%) Living at home Care home resident Permanent carer Mobile with aids Assistance with ADL
86.5 (3.2) 80–90 6 (75) 17.8 (5.9) 8–25 6 (2.6) 4–12 25 (12) 18-48 7 5 4 3 2 2 2 1 1
(88) (63) (50) (38) (25) (25) (25) (12.5) (12.5)
5 3 2 5 5
(63) (37) (25) (63) (63)
SD, standard deviation; COPD, chronic obstructive pulmonary disease; ADL, activities of daily living. *Characteristics at the point of complete hypoglycaemic medications withdrawal.
ª 2014 John Wiley & Sons Ltd Int J Clin Pract, June 2014, 68, 6, 790–792
12 Patient-1 Patient-2 Patient-3 Patient-4 Patient-5 Patient-6 Patient-7 Patient-8
10 8
HbA1c (%)
Baseline characteristics at the point of complete medications withdrawal are summarised in Table 1. Seven of the eight patients were on insulin therapy (four patients were on insulin in combination with oral hypoglycaemic medications and three patients were on insulin alone). One patient was only on oral hypoglycaemic medication. Tight glycaemic control (HbA1c ≤ 6%) was the main reason for medication withdrawal in two patients while recurrent episodes of hypoglycaemia were the main reason in the other six patients. Hypoglycaemic medications were completely withdrawn over a 3–6 months and the follow-up was 1 year period after complete withdrawal. There was no deterioration of glycaemic control over the follow-up period (Figure 1). There was no significant difference between the mean (SD) of HbA1c at the point of hypoglycaemic medications withdrawal and at 1 year of follow-up, 6.2% (0.8)
791
6 4 2 –6
–3
0
0 3 6 Duration (months)
9
12
Figure 1 HbA1c (%) values for the eight patients 6 months before and up to 1 year after complete withdrawal of hypoglycaemic medications
and 6.5% (0.7), difference of 0.3 [95% confidence interval (CI) 1.1 to 0.5, p = 0.4], respectively. Liver and renal functions were similar at the point of medication withdrawal compared with their levels at the point of introducing diabetes treatment. On the other hand, demographic characteristics of patients have changed significantly between both points with increasing the mean level of comorbidities (4.1 vs. 6.8, difference 2.7, 95% CI 1.3–3.9, p = 0.002), number of medications (6.4 vs. 10.1, difference 3.7, 95% CI 1.4–6.1, p = 0.01) and decreasing weight (88.0 vs. 75.4 kg, difference 12.6, 95% CI 5.9–19.3, p = 0.003). Successful withdrawal or reduction in hypoglycaemic medications has been shown previously in a cohort of frail nursing home older patients, mean (SD) age 84.4 (6.8) years with diabetes (3). The main characteristics of our cohort of patients at the point of hypoglycaemic medications withdrawal were the significant weight loss, increased comorbidities and polypharmacy which are all risk factors for hypoglycaemia. It is likely that this cohort of patients have become very frail with increasing weight loss leading to recurrent hypoglycaemia. It is known that diabetes mellitus increases the risk of lean body mass loss or sarcopenia than in persons without diabetes increasing their risk of developing frailty (4). At the point of hypoglycaemic medications withdrawal, five (63%) patients needed help with activities of daily living and three (37%) were admitted to care homes. It has been previously shown that markers of underlying frailty such as older age, use of multiple medications and frequent hospitalisations are associated with increased risk of hypoglycaemia (5). At the point of hypoglycaemic medications withdrawal, four (50%) patients were already diagnosed with dementia. The risk of hypoglycaemia has also been shown to be higher in patients with dementia or cognitive dysfunction (6). In summary, our cohort of patients were very old, have multiple comorbidities including dementia and polypharmacy that contributed to frailty
and frequent hypoglycaemia. Therefore, hypoglycaemic medications withdrawal in such patients including insulin appeared to be safe and might decrease the risk of hypoglycaemia with its serious consequences (7). Although current guidelines (8) suggest less tight glycaemic control in frail older people with diabetes, it does not explicitly recommend complete medication withdrawal which we believe it should be considered in certain patients. A. H. Abdelhafiz,1 P. Chakravorty,1 S. Gupta,1 A. Haque,1 A. J. Sinclair,2 1 Department of Elderly Medicine, Rotherham General Hospital, Rotherham, UK 2 Bedfordshire & Hertfordshire Postgraduate Medical School University of Luton, Luton Bedfordshire, UK E-mail: [email protected]
References 1 Wakimoto P, Block G. Dietary intake, dietary patterns and changes with age: an epidemiological perspective. J Gerontol A Biol Sci Med Sci 2001; 56: 65–80. 2 Abdelhafiz AH, Sinclair AJ. Hypoglycaemia in residential care homes. Br J Gen Pract 2009; 59: 49– 50. 3 Sjoblom P, Tengblad A, Lofgren UB et al. Can diabetes medication be reduced in elderly patients? An observational study of diabetes drug withdrawal in nursing home patients with tight glycaemic control. Diab Res Clin Pract 2008; 82: 197–202. 4 Lee JSW, Auyeung TW, Leung J, Kwok T, Leung PC, Woo J. The effect of diabetes mellitus on age-associated lean mass loss in 3153 older adults. Diabet Med 2010; 27: 1366–71. 5 Shorr RI, Ray WA, Daugherty JR, Griffin MR. Incidence and risk factors for serious hypoglycemia in older persons using insulin or sulfonylureas. Arch Intern Med 1997; 157: 1681–6. 6 Feil DG, Rajan M, Soroka O, Tseng CL, Miller DR, Pogach LM. Risk of hypoglycemia in older veterans with dementia and cognitive impairment: implications for practice and policy. J Am Geriatr Soc 2011; 59: 2263–72.
792
Letters
7 Goto A, Arah OA, Goto M et al. Severe hypoglycaemia and cardiovascular disease: systematic review and meta-analysis with bias analysis. BMJ 2013; 347: f4533. doi:10.1136/bmj.f4533.
8 American Diabetes Association. Executive summary: standards of medical care in diabetes-2014. Diabetes Care 2010; 37: S14–80.
Disclosure None. doi: 10.1111/ijcp.12455
ª 2014 John Wiley & Sons Ltd Int J Clin Pract, June 2014, 68, 6, 790–792
