Complexity of generalism: the 10 minute asthma case

Cases and topics

Detail of the case has been changed to maintain confidentiality

A 55-year-old patient who holds a managerial position at a supermarket chain and suffers from asthma recently came in for a medical consultation due to his asthma symptoms worsening. The adjustment of his asthma management plan, including the introduction of montelukast, was a recent change made after discussions with both a pharmacist and a general practitioner to better control his condition.

During our session, the patient expressed concerns beyond his physical health, particularly relating to the stress he experiences at work. He detailed the strain of having to shoulder extra responsibilities after his direct supervisor took a medical leave, leading to an overwhelming workload. This situation prompted him to request a two-week sick note to alleviate his stress and manage his asthma symptoms more effectively.

Our conversation also delved into the potential impact of his work stress and the environment on his asthma exacerbations. Despite modifications to his medication regimen showing signs of improvement—evidenced by decreased coughing at night—our discussion also covered the importance of ruling out serious conditions like pneumonia or lung cancer through the absence of symptoms such as fever and weight loss, and environmental factors like resolved issues with household dampness.

The patient also mentioned experiencing diarrhea and having a history of gastrointestinal issues following a past surgery. This raised questions about the relevance and possible connection of these symptoms to his current asthma medication, montelukast, which he suspected might be contributing to his gastrointestinal discomfort.

Upon physical examination, the patient was found to be stable, with the exception of bilateral wheezing. His vital signs were normal. Given the suspicion that montelukast might be causing side effects, we decided to discontinue the medication and monitor his symptoms closely. If his symptoms improved upon discontinuation, we planned to reassess the medication's role in his condition.

In light of his symptoms and the desire to improve his quality of life and work readiness, a course of steroids was prescribed despite no evidence of infection, as antibiotics were deemed unnecessary. It was after this decision that I realized the omission of his diabetes and a history of depression from our discussion, neither of which had been managed or addressed during our consultation. This oversight underscores the importance of a comprehensive approach to patient care, recognizing the need to consider all aspects of a patient’s health history in the management of their current condition. I also needed to complete a yellow MHRA form.

What you need to know to manage this case

Asthma: diagnosis and management

Differential of a cough and wheeze

Diarrhoea: diagnosis and management

Social determinants of health

Mental health in asthma

Medication: monteleukast indications, benefits, risks, alternatives

Steroids: indications, risks, benefits and alternatives

Fit notes: indications and process

Occupational health

MHRA yellow forms

Consultation: structuring, navigation

Shared decision making

EMIS IT use

Safety-netting

Tensions and dilemmas

The narrative presents several tensions and dilemmas that stem from the interplay between personal health, workplace stress, and medical decision-making. These elements collectively create a complex situation for the patient and the doctor, revealing more profound insights into their motivations, values, and responses to their challenges.

1. Health vs. Work Responsibilities Dilemma: The patient, a manager at a supermarket chain, faces the dilemma of balancing his health needs with his professional responsibilities. The tension arises from his asthmatic condition, exacerbated by workplace stress, especially after taking on additional duties due to his manager's absence. This situation underscores the patient's dedication to his role and his sense of duty despite the physical toll. His request for a sick note reflects a critical decision: prioritizing health over professional obligations. This dilemma highlights the broader issue many face in prioritizing personal health in demanding work environments.

2. Stress as a Trigger for Health Issues: The GP ponders whether the patient's asthma exacerbation is stress-related, introducing a dilemma of addressing the root cause versus treating symptoms. The tension lies in the intersection of environmental factors and health, suggesting that solutions may extend beyond medical treatment to include lifestyle and workplace adjustments. This situation reveals the doctor's holistic approach to health care, considering factors outside traditional medical parameters. The decision to explore the occupational component of the patient's health issues emphasizes the importance of a comprehensive approach to health, acknowledging the impact of stress and work conditions.

3. Decision to Discontinue Medication: The decision to stop montelukast due to potential side effects presents a dilemma between managing the patient's asthma and addressing new, possibly drug-induced symptoms. This tension between effective asthma management and avoiding adverse side effects showcases the complexity of medical treatment, where actions to improve one aspect of health might compromise another. It reveals the doctor's cautious and responsive approach to treatment, prioritizing patient safety and well-being. The resolution involves monitoring the patient's response to the change, highlighting the adaptive nature of medical care.

4. Overlooked Health Conditions: Discovering the patient's diabetes and depression at the consultation's end presents a dilemma related to comprehensive care versus the focus on immediate health concerns. This oversight points to the tension between managing acute issues (asthma exacerbation) and recognising chronic conditions that also require attention. It reflects challenges in balancing immediate patient concerns with a holistic view of their health history and needs. The unresolved nature of this dilemma suggests the ongoing challenge of ensuring comprehensive patient care within the constraints of time-limited consultations.

Generalism

The concept of generalism, especially in the context of healthcare, refers to a holistic and broad approach to patient care, where the practitioner takes into account not only the specific ailment but also the patient's overall health, lifestyle, and external factors affecting their well-being.

For Generalism:

The doctor's approach to the patient's care embodies generalism by considering the wide range of factors affecting the patient's health, beyond just the immediate symptoms. The acknowledgment of workplace stress, the impact of the patient's living conditions (such as dampness in the house), and the exploration of potential side effects from medication (like montelukast causing diarrhea) illustrate a comprehensive consideration of various health determinants.
The doctor's inquiry into the patient's mental health history and the recent exacerbation of asthma symptoms due to workplace stress highlights a recognition of the interplay between mental and physical health, a key principle of generalism. This holistic view is further evidenced by the concern for the patient's unaddressed diabetes and depression, indicating an awareness of the need for comprehensive patient management.

Against Generalism:

However, there are instances where the generalist approach is seemingly compromised or limited. The initial oversight of the patient's diabetes and depression until after the consultation suggests a gap in the integration of the patient's full medical history into the current care plan. This could be seen as a deviation from the ideal of generalism, where every aspect of the patient's health and well-being should be concurrently considered.
The focus on adjusting asthma treatment and managing its immediate exacerbations, while necessary, also momentarily narrows the scope of care to a specific health issue. This could be interpreted as a momentary shift away from a fully generalist approach, where the immediate clinical need temporarily overshadows the broader, holistic view of the patient's health.

The doctor's approach largely aligns with the principles of generalism through its comprehensive consideration of the patient's physical, environmental, and mental health factors. The effort to understand and treat the patient within the context of their life circumstances, health history, and external stressors demonstrates a commitment to holistic care. However, the occasional oversight and the focus on specific issues at the expense of others highlight the challenges inherent in practicing generalism fully. These moments remind us of the complexities and limitations faced by healthcare providers in balancing immediate medical needs with a broader holistic approach. Overall, the scenario supports the idea that while generalism is the goal, achieving it requires navigating practical constraints and continuously striving for a more integrated understanding of patient care.

Traps and pitfalls of the generalist

The scenario with the asthmatic patient presents several traps and pitfalls for the doctor, reflecting challenges in generalism, clinical decision-making, communication, and holistic patient care. Here are some key areas of concern:

Overlooking Comprehensive Patient History:
- Failing to consider the patient's complete medical history, including diabetes and depression, which were not addressed during the consultation. This oversight can lead to suboptimal treatment plans that don't consider the patient's overall health, potentially exacerbating existing conditions.
Time Management vs. Patient Care:
- Prioritising time efficiency over thorough patient engagement and exploration of all health concerns. While time constraints are real, rushing through consultations can miss significant health issues, reduce patient satisfaction, and potentially lead to inadequate care.
Managing Work-related Stress:
- Underestimating the impact of stress and occupational factors on the patient's asthma and overall health. Failure to address these factors comprehensively can result in recurrent health issues, leading to chronic instability in the patient's condition.
Medication Management:
- The decision to start, stop, or change medications without fully considering potential side effects or the patient's unique health context. This could lead to adverse reactions, non-adherence to treatment plans, or unresolved health issues, affecting patient outcomes.
Communication and Patient Involvement:
- Not adequately involving the patient in decision-making or failing to communicate the rationale behind certain decisions, like medication changes. Poor communication can lead to misunderstanding, lack of trust, and non-compliance with treatment plans, hindering effective management of the condition.
Holistic Approach:
- Concentrating on the physical symptoms without integrating mental health and lifestyle factors into the care plan. Neglecting aspects of mental health and lifestyle can prevent a truly holistic approach to patient care, potentially missing critical elements of treatment and support.
Documentation and Follow-up:
- Inadequate documentation of patient encounters and follow-up plans. This can lead to continuity of care issues, with significant information being overlooked in future consultations, affecting patient safety and treatment efficacy.