Quote:
Originally Posted by Unregistered
You don't know what you don't know. A well trained fp has mastery of the consult and can do a lot in 15 minutes. Usually this is the m.med fp who while preparing for the clinical really really learn how to handle the complex consult. Fcfp level even more complex. They throw pages of discharge summary at u to figure out what to do in 10 minutes.
A while ago I had a gdfm colleague saying m.med nia, what's so difficult, like gdfm , so he went to do.
Till date , mcq 2nd time already haven't pass. I arm chio always.
I've seen gdfm fp give nitrofurantoin for male UTI, some more that fellow has ckd.
Wrong on so many levels. My resident do that...I will really slap them.
Lots of gdfmers also cannot manage diabetes well. To them it's about upping oral med till cannot , recommend insulin, patient reject , case close. Even simple things like checking when patient take glipizdr they also dunno. Diet history also dun take. Many a times I dun even increase oah dose but just changing the medication administration timing, hba1c improve liao. My resident come to me without checking diet and how meds are taken I will really lecture them
26 year old boy BP 160/80, to start amlodipine for hypertension and arrange hypertensive panel 2 months later. Turn out patiet had lupus nephritis, egfr 15 nia. Like hellow...use some brains can or not. Not all hypertension is essential hypertension lei.
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I agree with your point but at the end of the day, coming from a resident point of view, I honestly feel that a lot of knowledge we gained in mmed are good to know, but may not be very common or applicable in real life. And let's be honest, other than RCC, it is quite hard to do a proper mmed consult if we are running a normal queue in our block posting.
Personally, I might sound controversial but I feel that we also need to be realistic about our roles as doctors.
Our job is to diagnose correctly and recommend the appropriate treatment. We are not responsible for our pt health- patient themselves are responsible for their own health. We are simply a resource person to give them relevant professional advice and guide them along the way. If pt don't want to listen, we also cannot force them. (Remember autonomy is the 1st of 4 ethical principles)
Like poorly controlled DM, agree that med adherence, diet history is important, but if pt don't want listen or follow our advice, who are we to scold/lecture them?
The in thing nowadays is shared decision making, which means that not always the right/best decision is made, and our job is to ensure that patient understand the consequences of their poor decision. This can range from refusing surgery/AOR discharge in hospital setting to medication non adherence for chronics in outpatient setting, leading to long term health issues.
Some of these people have poorly controlled DM for years, and multiple doctors including seniors (with mmed or even fellowship, some even seen by my head of ops) have counselled them extensively but they just don't listen. What the hell are we supposed to do? After all, We are just a resource person for our pts, and not God.
A lot of times we write-"declined med titration, tcu 3 months". Actually we might have spend a lot of time talking to pt, telling them of micro/macro vascular complications etc, just that we obviously can't document everything we said (as we only have 10 min)
A lot of times there are also many other fundamental reasons that I can't solve. Few examples
A) financial reasons and cannot afford medicine
- let's be real, other than refer msw, what else can I do? Teach him how to make more money, go upskill himself and get a better job?). Sometimes these people are foreign workers, even msw can't do much.
- I can give him relevant diet advice, healthy plate concept etc. But many patients have told me that it is actually a lot more expensive to go for healthier options in Singapore (esp for those who predominantly dine out and dont cook), as the cheap hawker stuff are usually unhealthy (even if they make a conscientious effort to choose those with healthy option labels)
B) interaction of disease (I have seen pts with schizophrenia, intellectual disability or cognitive impairment who have poor or no insight to their condition, no caregiver available) a little hard for me to recommend med changes or educate on diet- might even be dangerous to start insulin for some of these cases.
C) fixed beliefs
- some of the elderly just believe in tcm more, and don't believe in western meds.
- some don't believe in taking meds until they develop symptoms (despite me telling them they might remain asymptomatic until they develop complications)
- can keep nagging, but a bit hard also- you try too hard and lecture them, they will complain you for being too rude..
I am still learning as I believe FM is a lifelong learning journey. Just wanted to rant/highlight some of the practical difficulty that I face during my ops posting.
But I honestly believe that it takes 2 hands to clap for chronic disease management to be done well. Patients themselves are responsible for their own health and doctors are the resource person to guide them with our medical knowledge. We are not here to babysit them as ultimately it's their own body.