Issue 17 / 11 May 2015

A RESEARCH paper published last month in the MJA and reported in MJA InSight, made quite a splash in the medical and lay media.

Based on a large study of computerised general practice records, the researchers found that only 22.2% of patients had their body mass index documented, and just 4.3% had a record of their waist circumference. The imputation was that GPs are not monitoring patients for overweight and obesity, and are therefore failing to manage these health risks.

As a former GP, I bristle a bit at these kinds of studies. I know that failure to document something does not always mean failure to consider it; that recording basic parameters might be a low priority in some consultations, and that measuring something does not equate to managing it.

In an article in The Conversation last week, two Melbourne-based academics went further in questioning the importance of documenting measures of overweight and obesity, arguing that GPs would be better off spending their time listening to their patients to discover the reasons why they may be above their most healthy weight, than weighing and measuring them.

While the article left me feeling like I’d been presented with the old “if a tree falls in a forest” conundrum, it touched on an important issue in medicine that is also raised by two very different MJA InSight articles this week. What is the value of measurement and documentation, and what are the risks?

An MJA study published online and reported in our first news story, has found almost half of all Australian adults with asthma have poor symptom control, much of which is avoidable with appropriate management.

Commenting on the study, respiratory physician Hubertus Jersmann told MJA InSight one barrier to effective management was that doctors were simply not aware of their patients’ symptoms, and suggested that that GP surgeries use routine patient questionnaires to document asthma status.

“The more questions we ask a patient, the more we can control their asthma”, he said, making the reasonable assumption that the first step to managing something is knowing about and documenting it.

Another of our news stories reports on a US study that found stroke patients treated in hospitals with electronic health records (EHRs) were no more likely than those at other hospitals to receive high-quality care, and had similar outcomes.

Speaking to MJA InSight, Dr Steve Hambleton, chair of the National E-Health Transition Authority, observed that the function of EHRs needed to move beyond documentation, which, after all, might just be providing an accurate account of substandard care.

“If you mechanise medical records by creating an EHR, there will be no change. But if you re-engineer what you do with that information, that’s when we should get some leverage”, he said.

Failure to act on documented problems is not a new phenomenon, nor is it confined to any one aspect of practice. Studies that show deteriorating clinical signs in hospitalised patients were often documented yet not acted upon before critical events underpinned the development of medical emergency teams (or rapid response systems) almost two decades ago.

What are the risks of measurement and documentation?

The authors of the article on obesity in The Conversation say weighing and measuring can be off-putting to patients and might distract doctors from the main game of getting alongside their patients and looking at the root causes of weight problems.

Failure to recognise that documentation is not an end point is a real risk, but surely it is better, if possible, to sensitively obtain the data, record it and use it to objectively monitor the outcomes of management.

Documenting something doesn’t lead to change — but before you do make a change you probably should document it.
 

Dr Ruth Armstrong is the medical editor of MJA InSight. Find her on Twitter: @DrRuthInSight

6 thoughts on “Ruth Armstrong: On the record

  1. Dr Robert McEvoy says:

    People do not want to be defined in terms of their “illness”, as we know it, whether it is asthma, obesity or cardiovacular events. They see themselves as well people who are bothered from time-to-time by issues that necessitate a short visit to their doctor. I am sick of so-called ‘experts’ telling other doctors that obesity or asthma or whatever is out of control because doctors don’t measure something. The measureable for patients comes under the heading, What is in it for me? The asthmatic might measure outcomes in terms of how often he can kick footy with his son or have sex with his wife and not run out of puff, not how many reliever inhalers he is using a month. Until the profession gets into the heads of our patients and sees things through their eyes, we are never going to change anything of note, with or without the assistance of ‘experts’.

     

  2. Philip dawson says:

    I dont routinely measure waist circumference, but I do do weight’, blood pressure and if asthmatic or emphysema I measure FEV1 with a PICO 6. It doesnt take long and it allows the patient to think about how they feel and ask questions.  A record of weight over time is quite useful, weight steadily increasing or decreasing over 2 years and obvious on a graph can get both doctor and patient thinking about what is going on. If you are doing paper based 6 minute medicine then yes, there is no time for this, but if you do computerized 15 minute consults, and have a nurse for EPC items, there is plenty of time to do this. Sometimes its what the patient is eating, more often our chronic patients (diabetic ande heart disease) have got the heath message and don”t eat a lot of the wrong things, they just eat too much and do too little exercise This idea went “thud” for a patient recently who despite being very overweight and unable to move much lost 20 kgs in a few months. He said he discovered the secret to weght loss – eat less!

  3. Dr Louis Fenelon says:

    The previous 2 comments are really accurate, if opposites. We have no right to impose bureaucratic rules on our patient attending for their own reasons. Researchers and medicopoliticians do not deserve ticked boxes for demanding we do impose their rules.

    If you are not a primary care doctor, in their practice and in their shoes, any need to influence how the consultation goes is manipulating all evidence that GP’s actually get it right at lower cost than other medical services. To even consider a non-practitioner (committee etc) knows what every patient needs is sick in itself! On the other hand, if you support the need for numbers over people you can make money from doing nothing by delegating duties to other practice staff whilst somehow proving you really have a handle on all your patients’ health.

    The reality is doctors don’t remember numbers, we remember patients and our patients remember us. If you are a caring GP, you know they know you know about the overweight, diet disasters, family stress and issues at work. IMHO these are things that do not get fixed by measuring fat people every few months of their life. I despair of a medical system that rewards us turning our face away from patient care to make money by satisfying the beliefs of non-practitioners who have no status a real primary care environment.

    For the bureaucrats who think they should manipulate a proven, high quality primary care system – butt out. For the doctors who see fulfilling the needs of the system above the needs of the people who count on your care – you may be too busy, or maybe too focussed on what you can get out of your patients than what you can offer them. Good medicine is not a numbers game.  

  4. Ulf Steinvorth says:

    Failure to act on documented problems seems to be reflected in the MJA’s silence on the silencing of its chief editor for his concerns about quality of this journal.

    Will we get an open, evidence-based discussion on what is going on as we should be able to expect?

     

  5. Peter Penn says:

    I’m not a GP but when I go to my GP I have simple typed out form I’ve developed with my measurements for weight and waist at the top and my last measurements underneath. So I do my weight and waist just before I go. My GP appreciates this time saver and starts a discussion on these measurements. Below on my ‘GP  form’ is a list of why I’ve book the appointment . With my help,  my GP has time to discuss the important lifestyle aspects of my health. I feel the solutions to improving health should include increasing the particaption of patients in their clincial care. I aslo feel GPs could help patients with a summary prescription with space for the patient to take notes on thier provisional  diagnosis, current treatment and what to do if treatment has complications, review and referrals and when to do that. This on top of a pharmaclogical prescription, and  pathology and imaging referrals that a paient may get in a consultation. It shouldn’t take extra time if the patient is doing the recording if they are able to do that. 

  6. Caitlin Raschke says:

    Have you read the obesity guidelines? They seem like so much nutritional advice to be based often on opinion rather than evidence. Most (not all, I know) people who are overweight don’t need to be told, so laboriously measuring them is not necessarily time well spent. It’s not a revelation to these people to put a figure on how overweight they are, but it is often depressing. The way to an effective therapeutic relationship is not always to smack the patient in the face.

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