HOW TO TREAT 23
ausdoc . com . au 14 FEBRUARY 2025
HOW TO TREAT 23
Figure 3 . Crisis and emotional response .
Box 2 . Appraisal and education
• Acute appraisal of the situation : Patients who overestimate the threat may become paralysed by anxiety , or become fatalistic , and withdraw from medical care . Patients who underestimate the threat can delay interventions or avoid them altogether . In early consultations , the patient is easily overwhelmed , so early goals focus on : — Ensuring they know the name of the condition , and know whether the diagnosis is certain or still under investigation . — Ensuring they have an accurate idea of the seriousness of the condition . It is helpful to use phrases like “ If it is cancer , it is treatable .” Hope is important , but so is honesty . — Ensuring they have an accurate idea of the urgency of treatment or investigation . It is helpful to use phrases like “ We need to do some investigations as soon as we can so I will organise an appointment with one of the specialists to arrange the next steps .”
— Ensuring they understand what they need to do in the next 24-48 hours , including offering to meet with family members to explain the situation and seeing them again in three days . If possible , ask your practice nurse to contact them the following day to check they have understood what they need to do , and to offer support . — Making sure they are safe to make their way home and have access to support when they get there if they need it .
• Ongoing appraisal : Managing an ongoing illness means considerable and often rapid learning . This requires : — Health system literacy , which involves understanding the structure of healthcare and the people within it . We often forget how fluent we are in the language of hospitals and specialties . I often start this conversation with the comment “ Medicine and hospitals are full of jargon . Would you like me to run through who is likely to be involved in your care and what they all do ?”
— Illness narratives and illness behaviour , which describe the personal and cultural beliefs people hold about their bodies and minds , the way they become ill and the way they heal . Although individual understanding of illness changes over time , coping usually needs to fit within the illness beliefs a person holds . Usually , we learn this during interactions with patients . It is important not to imply that an illness is a person ’ s fault , so I tend to start asking about recovery with a question like “ Everybody is different , so I just want to get a sense of how you manage your health . What do you think is important for you to get healthy again ?”
— Health literacy , which describes the ability of patients to access , understand and use health information to benefit their health . It is helpful to screen for issues around literacy and numeracy , without triggering shame . I often ask the question “ I ’ d like to help you understand this illness , but it can all get a bit overwhelming , so I wanted to ask how you prefer to find out about things . Are you a person who likes to talk it through , or do you tend to use things like brochures or websites ?” If you need to be more specific , I tend to ask “ Websites are often difficult to read , because they ’ re full of jargon . Lots of people have trouble getting information out of a website . Is this something that happens for you ?”
— Digital literacy is the ability to access , manage , understand , integrate , communicate , evaluate and create information safely . It is difficult to develop these skills without access to a device , so it is often a problem for patients who live in poverty .
• Education : — People cannot cope if they do not understand the problem . Good explanations avoid medical jargon . It involves breaking down information or instructions into small concrete steps , limiting the focus of a visit to three key points or tasks , and assessing for comprehension .
— Printed information should be written at or below a year five or six reading level . 2 Visual aids , graphs , or pictures can enhance patient understanding . Be aware that many people do not have a good internal body ‘ map ’ so diagrams may not be helpful . Sometimes , it is easier to show the patient where the problem is on their own body , or in some cases on an external picture of a person , rather than a diagram of internal organs .
— Assessment of risk is more difficult than we think . Graphs are best shown as bars , numbers or pictograms . 9 Use as little maths as possible , removing anything that is non-essential . Anecdotes are helpful ( eg , “ So that would mean if I had 10 people in this room , I expect one of them to get better ”). It is also important to check a person ’ s understanding of numerical content ( eg , “ So what do you think this means for you ?”).
overwhelmed . The first part of this stage is defining what the problems are , and deciding those of highest priority . The next stage is working through the list , often over several consultations , to not only identify the patient ’ s resources , but also to offer resources available through the healthcare system . Social workers can be particularly helpful , although they are frustratingly scarce in the public system . Structured problem-solving techniques are summarised in box 3 , and there are many templates available online .
EMOTION-FOCUSED COPING SKILLS
IN times of great stress , many people will resort to unhelpful emotion-focused coping strategies , which generally involve avoidance . Substance abuse , gambling ( see figure 5 ) and compulsive internet use may temporarily allow people to avoid feelings of anxiety ; however , these are not helpful in the longer term and some are dangerous . There is an upsurge in domestic abuse as people redirect their emotions into violence . Some anxious patients show extreme responses to stress ; they may have stopped eating because they are afraid of shopping , or they may practise compulsive cleaning . Emotion-focused coping may also mean people avoid stress by pretending the problem does not exist or engaging in risky behaviours . It is understandable that people will use these emotion-focused techniques , but it is not helpful . As GPs , we have a role in modifying this behaviour where we can .
Positive alternatives are highly individual , but are well described in positive psychology . 11 People have preferences for their own resilience strategies , and it is important to find out what they have used in the past to help emotionally regulate . Potential examples of emotion-focused techniques are detailed in table 1 .
Figure 6 illustrates modifying coping using appraisal and coping strategies .
MEANING-FOCUSED COPING SKILLS
PROBLEM-FOCUSED and emotion-focused coping have their limits , because stress can remain no
Box 3 . Structured problemsolving steps
1 . Make a list of all the problems you can identify .
2 . Clearly define one problem that you think is important , as specifically as possible .
3 . Brainstorm as many solutions as you can :
• List any solutions even if they seem useless or absurd .
• Do not evaluate at this stage , just brainstorm ; sometimes ridiculous ‘ solutions ’ can trigger useful and viable ideas .
4 . Evaluate the options :
• Briefly consider the advantages and disadvantages of each solution . Do not pick a solution yet .
5 . Choose the best solutions :
• Choose a solution or a combination of solutions that are achievable , even if it only meets one step in a longer process .
6 . Make a detailed action plan :
• Patients are more likely to take action if there is a detailed series of steps to follow , and the resources needed are defined and available .
• It is important to consider what can be done if there are obstacles that need to be overcome .
7 . Review your progress :
• Problems are often not completely solved after the first round of structured problem-solving ; the steps can be repeated .
As a GP , it is usually only necessary to do this structured template once , as patients will usually be able to follow the template themselves with encouragement after the first attempt . Source : This Way Up — Structured Problem Solving 10