What should I expect from my GP? with Regina Sit and George Peat

hello and welcome to this edition of joint action [Music] this podcast is dedicated to all those out there who have osteoarthritis on the show we unpack the truth and demystify the myths about the disease and its management if you have joint pain and want to know more about how to manage it from the world's best experts you've come to the right place without further ado it is time to welcome your host david hunter hello and welcome to this edition of join action this week we have the privilege of discussing what should i expect from my gp or primary care osteoarthritis is a frequent reason that a patient would visit their general practitioner or primary care physician and the predominant reason they would do so is because of pain and increasing activity difficulty gps are the primary point person in many healthcare systems and typically would be visited before seeing any other healthcare professional including for exercise diet or surgery many patients with osteoarthritis have other serious comorbidities within which osteoarthritis is just one of many complicated diseases and many modern healthcare systems typically don't afford long appointments that would afford behaviour change shared decision making and counselling that we are all encouraging in this context of patient complexity and the turnstile of primary care there are often challenges that patients face in getting adequate coordinated and appropriate care and to discuss this important and complicated area we're joined by none other than regina sit and george peace dr regina obtained her bachelor of medicine and surgery degree from the university of hong kong she's a family medicine specialist at the hong kong academy of medicine since 2011 and in addition to a specialist training she carries qualifications in pediatrics dermatology geriatrics and internal medicine as a family physician she develops special skills in pain management and is a certified interventional pain synologist by the world's institute of pain her clinical and research interests focus on the study of musculoskeletal pain in primary care she's passionate about exploring designing evaluating and implementing innovative interventions to improve the quality of life of those who suffer from chronic musculoskeletal pain currently she's the director of the hong kong jockey club pain relief project for seniors and is leading an interdisciplinary team for chronic pain management in primary care in addition to regina sid we're also joined by george pete who's a senior lecturer and clinical epidemiologist and physiotherapist who works at keele university in their primary care musculoskeletal research center george qualified as a physiotherapist in 1991 from queen margaret college in edinburgh before going on to gain a master's in public health sciences at edinburgh university and a phd in 1998 from manchester university he joined the arthritis research uk primary care center at keele university in 1999 regina and george welcome to the show hi hi there thank you very much for coming along now before we get into the meat and potatoes of the show any conflicts or disclosures of relevance no i don't i have no conflict of interest no i don't i should say that i'm involved in a trial just now of braces for knee osteoarthritis i'm not sure if they will crop up in conversation and i also hold an academic contract with public health england but i don't think either of those constitute the conflict i don't think so but in any way good that you disclosed it now the first part of the show i usually spend a little bit of time just asking you a few probing questions to get to know both of you a little better and so regina what i might do is if if it's all right i'm going to start with you okay sure but if you had to describe yourself in five words what would they be well i think about this i'm in five words maybe a self-motivated person with strong perseverance so i usually when i decided to do something i must finish it you're great great qualities to have very good qualities to have and professionally can you tell me a little bit more about what you do on a day-to-day basis at work so i'm a family medicine doctor and also a clinical academia i'm the associate professor of family medicine in the chinese university of hong kong so in my daily work i have three parts of work that i need to do first is research the second is about my clinical work see my patients every day and then i have to teach i teach a lot of medical students sounds like you have a very full plate what makes up the large portion of that balance very lucky because my research and clinical areas are focusing on the same things on dealing with different kinds of muscular skeletal complaints so i would say both of it fill up majority of my time during my work yeah now when you're not at work what do you enjoy doing well i'm a mother of two so usually after work i will spend time with my kids and just play as any mothers and usually after when i have my own private time i will go running running yes fantastic how old are your kids regina one is nine one is ten one boy and one girl so right in the thick of it it sounds it sounds like a very similar age to yours george yes yeah now george similar questions to you but if you had to use the same or not in the same five words but if you had to use five words to describe yourself what would they be well i was thinking about this we get we get so many of these tests that you have to do now to place yourself as a teacher or a learner i've been told that my style is particularly deliberative so i'm i wouldn't use the word ponderous but it kind of gets towards that end at times at rational i've been told that i have high integrity and i'm generally a supportive person they're all the nice things i won't listen together i've also been described yeah we don't need for you to share any of the not nice things here we just want to hear about the positive things again professionally when you're in your day job what is it that you do it's uh it's almost all research now although there's an increasing amount of training and teaching involved so we design research that is in primary care working in teams with our gp colleagues physiotherapists other healthcare professionals to design mostly quantitative research studies so these are studies involving large numbers of people who look at matters of diagnosis outcomes interventions and treatments and i'm involved in some of the teaching towards medical students and some of the the master's level training and phd student supervision too fantastic thanks for sharing that with us now obviously we've got you up early in the morning uk time so sleep can't be high on your priority list but what are the things that you do enjoy when you're not at work yeah like regina i've got two daughters aged 11 and nine so so they tend to keep me pretty busy so we have been doing a lot of ferrying tune from swimming that's their great passion used to be mines i have to say i occasionally get in the pool these days but not particularly gracefully um but i try and get exercise where i can but a lot of it i was afraid supporting them to to be the next generation of sports people that's superb when when you swim what type of event i mean did you compete at any point oh now you're going back in time yes should i say that i was an edinburgh champion at 50 meters breaststroke fantastic it was a it was a very small cohort that year i don't know but to what's uh that's that's excellent i uh did a lot of swimming in particularly ocean swimming growing up um and still remains an important passion of mine when the water's warm enough to get me outside yeah yeah obviously taking time away from the important topic of today which is really looking at how best patients can best engage in in primary care with their general practitioners and other healthcare professionals now a really important part of medicine is shared decision making i mean within the time limits of oftentimes constrained appointments within primary care how is it best to share information and counsel with patients particularly with regards their management choice regina i don't know whether you want to tackle that one first and then i might kick to george for another one unfortunately we don't have any tours that at this moment especially in our setting that actually help us to make a very effective shared decision making as a primary care doctor is in hong kong no matter you're a private or at a public setting we see quite a lot of patients especially if you're in a public setting we are seeing four t patients in the morning so each of them like got four to five minutes which will many of the time we spend a majority of the time in taking the history and then when it comes to the decision it's always the physician's decision it's more than well i would say there's not not really a kind of shared decision making so um we're really looking forward for one but it's a kind of very unfortunate thing we don't have it yet okay now george whether whether it be about information available in advance of the appointment or things that a person with osteoarthritis can do to prime themselves in advance any any suggestions topics thoughts on that on that regard yeah i mean certainly a group from our our university developed what we called an oa guide book so an osteoarthritis guidebook which is quite a comprehensive written sort of information that's publicly available and i i think that that's that's we've found that that's quite a good resource often for people not everybody uh really but some people find that that's both either reading that prior to uh going to see the doctor more often it's afterwards when it's recommended as a way of reinforcing information that's given in the consultation but that can help just crystallize some thoughts and hopefully there's quite a lot of stuff out there now about things like shared decision making and decision aids etc there seems to be angled a lot towards the decision about where not to have a joint replacement um there seems to be much less at that earlier stage in primary care where you're looking at the non-surgical options and i suppose if one were to be critical of those there's a big variation in the quality of these things and it's not entirely clear that they're always reaching the people that might need that information the most so it might be that these sorts of options where bm health the mobile health options others may be favoring those that are slightly more able to access you know online resources for example so i would say that the consultation still remains a really important place where you exchange information [Music] and i think just listening to the patient's agenda is probably one of the first and most important things that a primary care professional can do yeah yeah so just i guess quickly just to recap what you were saying there i mean i think obviously there are some written resources that that are available what george we might do is just provide a link to that resource that you just mentioned in the show notes so that people can access that and that they might be able to read that in advance of seeing their primary health care professional to better inform them about the disease and or the questions that they might propose to ask in in that consultation period um obviously focused on what their most important concerns and goals might be yeah now george i might kick to you in the first instance for this one but another really important element of treatment around osteoarthritis is that of behavior change such as exercise and weight loss and particularly adherence or sticking to that behavior change over time now what role if any should someone in a primary care health professional context have in optimizing that and in particular given some of the studies that are out there does nihilism about treatment to non-surgical approaches potentially erode some of that credibility and belief in those treatment options well i think that that's that is pretty undeniably true i think a lot of the evidence that's been accumulating now both from uh studies that are listening to the accounts that patients give as well as other studies looking at what factors might determine whether or not you go back to the doctor and raise your problem with them about your joints suggest that if you anticipate or experience a kind of fairly negative downbeat well there's nothing much we can do here i think that tends to have knock-on consequences both to the willingness to seek that support from healthcare professionals but also your own optimism about managing this and having our having a better outcome so i think it's really important that that sort of positive approach to trying to manage this non-surgically not just a waiting for when we might need to think about a joint replacement is really important and i think a lot of the ideas about self-management and clearly self-management is essential i mean people know that they live with it and they've got to manage it but what they often tell us is they want some support for that and they look to health care professionals in primary care to provide that not just the gp but of course the wide range of health professionals that have contact and influence so if anybody's tried to lose weight or try to exercise you know that it's a bit of a rocky uh road you don't you you don't just succeed miraculously it's it's something that you sort of go through troughs and peak satins and sometimes it needs somebody there and sometimes that's the primary care health professional to support and just provide that additional bit of motivation really in the work that you've done at heel where you presumably interacted with a lot of gps who work in that context are there any important characteristics or qualities about those types of interactions that you've seen that work well in in affirming or making that experience a positive one yeah that's a good question i mean i suspect that underlying all of it is that relationship between the primary care professional and their patient i think if that's a trusted one that's based on you know a mutual respect i think the opportunity to support long-term changes in behavior is that much better so i think it requires that underlying and enough and then you're talking about the sorts of communication skills i think that healthcare professionals may have and clearly some do this better than others but when you see it done well actually you can see patients leaving the consultation with renewed sort of energy and resolve and that is important yeah that's really helpful regina i mean obviously you were relying to us before that you see 40 people in the morning they've got four to five minutes of peace yeah how how do you achieve that it's quite difficult when you have a lot of patience but sometimes when i have my clinic that i only got by when i'm teaching at my teaching session i only may have 10 to 12 patients and it will be much easier because it really takes time i agree with george that many gps they don't really encourage their patients to criticize so they just take exercise as one of the prescription one of the sentence they need to talk they didn't tell the patients but they don't really motivate them to do that so some gps they didn't they didn't even exercise themselves so it makes them even more difficult to encourage others to do the same and for me i think the key for family physicians to help optimizing behavioral changes is really to explain to the patients why is important to exercise not only that exercise or other dietary control or weight reduction is good you also need to explain to them the relationship between for example why muscle strength is important for healthy joints once they get it they know that it's important but many of the time we just tell our patients oh let's go we'll have some exercise which sometimes they will they are not able to do that for example you ask them to run but they have the joint pain that makes the running very difficult so many of the time we have to tell them that there are a variety of exercise that can help your joints as simple as sitting exercise with the strengthening of the lower leg muscles it will help as well but i really the gp to explain to the patients how important it is are kind of like more tailor-made to their patients otherwise the patient after they listen to the gp they're not going to change their behavior i mean i think just really to reaffirm and state what uh regina and george is saying there i mean that positive affirmation that uh important relationship that a person has with that first contact is often often really critical and if it can be one where they're motivated and engaged to hear the message about what will be helpful for their joint health and ultimately hopefully reinforced at subsequent interactions as well and just checking in to see that that's uh they're retaining their goals and actually improving is so incredibly helpful and important the other thing is that the role of that wider team i think many people will now be seeing multiple members of a primary care team whether it's they're seeing the pharmacist or a nurse practitioner and these people often have quite important roles in the ongoing management of chronic long-term conditions i suppose the other point to note is that some of these behaviors losing weight exercising share their value across multiple conditions so whether it's diabetes or heart problems or cardiovascular health or mental health all of these things tend to operate well so there are probably multiple opportunities to the person that's got a few health problems to try and find a way of of making these sorts of behavior changes stick yeah and you know whilst we're obviously emphasizing the fact that oftentimes gps may not have time hopefully they do engage meaningfully with the other health professionals in their team whether whether that be a nurse practitioner or a physiotherapist a dietitian exercise therapist whomever it may be to help to reinforce a lot of those really important concepts now regina again you know gps occasionally have been known to normalize symptoms as part of a person's life and not validating the symptoms of osteoarthritis and occasionally they might use terms that include wear and tear now what steps can be taken to increase the priority of osteoarthritis as the disease in the minds of general practitioners and increase knowledge and how best to enhance the care that is delivered as a consequence well that's a really very good question that i'm also wondering well to me i think the most difficult part is that it's very difficult to engage our gp to focus their management on taking osteoarthritis neo-osteoarthritis or whatever because they've got a lot of diseases that they need to manage hypertension dm lipids obesity depression so sometimes i think it's the most difficult part is really to how to engage the gp to ask them to take some training or to explain to them i mean what's causing knee pain it's not always degeneration so many of my colleagues when they see patients with knee osteoarthritis what would they tell to the to the patients that oh you have degeneration and that's food stock however i would always say the degeneration is not maybe a normal process but it may not always lead to symptoms that lead to disability this concept is very important but we find it very difficult to actually tell every gps that it's not only degeneration there's a lot of things that we can do before the symptoms occur or at least we can reduce the stability of symptoms that's really helpful regina george do you have any elaboration on on that topic at all yeah it strikes with it it's it's a they're trading a a fine line often isn't it anyway i think on the one hand you don't want to over medicalize and start over treating and over diagnosing and over investigating something like osteoarthritis but clearly you also want to have a legitimate diagnosis you want to understand and have heard the nature of this problem and its impact which can be quite significant obviously on people so i mean my sense is that one of the things that can be done i think i absolutely agree with the gina that i think education for gp's and primary care professionals is very important here and that's that's across one's career not just at the start of it but i suppose i i also would look for fairly practical tips i think sometimes even just knowing the words to use when trying to explain the diagnosis of osteoarthritis we overlook because i think sometimes you reach for things like wear and tear with the best of motives but it's the wrong term it doesn't convey scientifically what we know to be true about the condition but i think it's an attempt to try and not frighten or worry or over medicalize the condition but actually i think there's there's other language here and better explanations that are needed and maybe some of the things that we could do is actually you know work out what are the right words to be using in the consultation one has to modify that for each individual but i think even those practical steps could be useful i suspect this is where some of the other health conditions may have got when explaining or giving the diagnosis and i think potentially that's also where some of the resources you're referring to before to increase a patient's own information base and health literacy around this topic could also be so important in engaging in meaningful dialogue around that what efforts are either of you aware of that are underway to i guess upskill increased knowledge base and engagement around osteoarthritis specifically obviously fully aware that the job in primary care is one that they see a lot of different complex non-communicable diseases but what efforts are underway to increase health professional knowledge base that you're aware of well at this point i would recommend you towards my colleague christia judge as well who's heavily engaged i think in a lot of initiatives to try and improve care on the ground with practitioners so engaging practitioners both in training and actually implementation they would call it so this is sort of implementation science now is not just discovering what works but actually trying to make sure that what works is actually happening in practice so i think those sorts of initiatives engaging not just gps but also pharmacists physiotherapists others in upskilling them giving them the practical tools to deliver better care and i suspect i mean those sorts of osteoarthritis management programs i think are you know increasingly an important part internationally of improving patient care so i know that there are examples in in your institution david but there are also ones in north america elsewhere in europe and and within the uk too and they appear to be a really really important step forward actually in the last few years yeah i mean there's a lot of effort underway there to increase the availability and accessibility of those programs and what the other thing that i might do just in response to the comment that you've mis just made there george is provide a link there to the knowledge translation acceleration unit that krisha uh leads up and runs there because i think that'll be a really helpful uh resource and link there regina any any thoughts comments on that no i agree with george um i think education should be on both sides so we should educating our patients by doing a lot of different kinds of either digital tours health education benefits or kind of very well wrapped up program for our patients but at the same time we also need to educate our primary care providers that they should actually write more explanation on the disease not so negative on the words not always telling patients that oh it's a kind of degeneration that nothing's that we can do that in fact a lot of things that we can do for example many of the time we see like 15 years old lady presented with knee pain and then the gp will automatically tell the patients that oh you're having a degeneration but she's just 15 it's not yet to degeneration yet but just that they cannot get other words to describe this why there's knee pain so they tend to use the word degeneration which is the kind of very discouraging so the women just come for leaving and then she knows that oh i've got degeneration that means i'm at the stage of aging so i think this is very important that it's not only for the patients but we also need to educate the primary care providers when they frame their works they try to explain in details what's actually happening and what things that actually we can do apart from watchful waiting that's really helpful um and obviously we've been outlining a lot of challenges and issues but what are the most pressing research needs in this field well to me we have a lot of research telling us that we should look for the disease modifying agents from the osteoarthritis which i think is important but in the primary care perspective i think we really need to look at the preventive measures what kinds of preventive measures or what are the combinations of preventive measures that once should be taken in order to prevent or to reduce the incidence of knee osteoarthritis or any kinds of osteoarthritis or to reduce the stability of symptoms if it's not going to reduce the incidence will it be going to reduce the severity i think this kind of preventive studies may take a few years to do it will be an expensive trials it's not easy to find the funders but i think this is important because once the gps or the patients know that if you're doing this a few years later you will be having less chance of developing a certain disease that will actually motivate both sides to do better so this is one thing and of course i also want to know about the education to me i i spent a lot of time to teach my gp colleagues on pain management i always have my question is how we can actually do the education research that we can assess not only the knowledge of the gps who receive the training but does the education actually change their behavior change their clinical practice and how it translates to a meaningful outcomes on our patients so this is very important we always say that we need a lot of training we need a lot of activities for our gps but how does it help and how is it going to translate to the care of our patients given that we also have the constraint of like time limitation for each consultation et cetera i fully fully agree with you that um you know if we're talking a lot about educating our healthcare professionals it's so important that we actually evaluate an audit to see whether we actually truly make a difference both to their knowledge base but ultimately probably more importantly to patient care george any thoughts well i would agree with an awful lot of what regina said and and support that i think like her i i think it's still important that we keep looking for new and novel disease modifying treatments of course but we mustn't put all our eggs in that basket and think that that's going to be the the sort of grand solution to this so i think what people would expect is that you're going to invest in ways of tackling this earlier i think the regret that people have sometimes as it's taken so long either to get a diagnosis or to get treatment working i think that we should be trying to understand when and how we get effective treatment in earlier and even further back in time look at what can be done to prevent some of the major drivers of this condition in the first place linking right back to your first podcast i suspect there and i think at the other end it's that dealing with the complex patient who's got multiple health problems we're all getting older it's aging societies around the world and i think how we maintain movement and activity in spite of joint problems is a major challenge so i think we've not quite worked out how to do that yet so i think there's still some important challenges as well so what's the most pressing research needed i think for research funders to start prioritizing some of the more funds towards osteoarthritis would be my solution to that so although everybody always asks for money don't they i think money well spent in osteoarthritis research could go a long way yeah a common theme that i often hear relayed during these conversations is the importance of apportioning this according to the disability that it causes in the community um which is obviously not happening at the moment anyway we're gonna get political if we go down that line are there any patient-friendly resources or links that you'd like to share that we haven't already spoken about that might shed further light on this topic i'm not sure because uh for me i always look for some tours in chinese because people here cannot many of them do not actually know how to read english so i i can't find any very useful useful one on the website but i do create some uh by myself so i make a lot of qr codes i in the old days we use our plant first so we we take the pictures and then we spread the exercise parameters to our patients but nowadays we all use the qr code so i have i take the videos and then i distribute the qr code to my patients and then when they go home they will they will do the exercise well i should do quite a lot i have like prepared a qr code and covering every part of the body fantastic that sounds like a wonderful resource if you've got a link please share it with us and we can put that in in the show notes i appreciate that qr codes and i assume is this in cantonese and mandarin uh he's in chinese in cantonese cantonese okay yeah but share that with us because i'm pretty sure we also have some chinese listeners as well george any any links that we haven't mentioned that you might like to share i feel positively lazy compared with that i think um i i would it may be a bit uk centric but i think versus arthritis as an organization produces a lot of very useful information for people with osteoarthritis so i would i would direct them towards that charities website in the first instance they have some excellent stuff fantastic that's really really helpful then regina again this is more just getting to know both of you a little bit better but i think my favorite question is why do you do what you do what motivates you well i always said this should be someone to do it for and things especially in hong kong i think well i think many of you who agree with me that we as primary care physicians deal with quite a lot of patients with different kinds of musculoskeletal pain and with neurosurprises is the communist one so we've got to deal with this so if we don't do it it just go to other orthopedics once you go to the orthopedics they will receive some what we call the no value care so they will go vaporoscopy and some of them will go totally replacement but having said that we still cannot deal with the large pool of patients having problems so to me i really want to improve the standard of primary care in musculoskeletal pain management because we are seeing them no matter you like it or you don't like it we have to see them because they always come back because of pain they review the medications they review the energy says they ask for topical medications they ask for referring to physiotherapy so we are seeing them so i'm always thinking about why you shouldn't be doing a little bit better to help the issues since you you have no choice your primary care physicians you cannot turn up with the patient and say that oh this is not within my school surface yeah it sounds like a great rallying cry to primary care out there because there is so much that can be done at that level and there's so much opportunity george any any thoughts in terms of why why you do what you do i'm scottish i was grown up with a love of the underdog and i i remember when i i moved from scotland to england it was to take up a job working in a chronic pain center and i think when i made that decision i think a lot of the people around me said oh my goodness really these are awfully difficult people and you you can't do anything for them when it's safe and that that to me is always thought well you know i'll we'll see let's uh we'll prove you wrong on that so and i still feel that osteoarthritis unfortunately despite its you know huge impact is the underdog in all of this i think there's still an awful lot that people like myself and others can do to find out more make life better make it a bit more prominent in people's minds and policy makers minds so i think that's what motivates me and then it's it's just i like working with people and i think that research is probably my thing so it's uh so it's a combination of those but uh yeah the underdog mentality still kind of does it for me really i'm sold i think i might do osteoarthritis research that sounds like a great career option all right um now george if you could have a billboard with anything on us what would it be and why oh i can take the tone first you can go through that so cool i would say the most terrible symptom in osteoarthritis is not pain but it's the laws of motivation to get better for the patients or to or lost the motivation to get someone better for the gp so this is for the billboard that i had stay positive stay hopeful yes yeah yeah no really really important and sage sagely advice george any thoughts after reflection so to me it would be it matters more than you realize i think it's it's on the surface this thing is something that affects lots of people everybody's got it all of this sort of nonsense but actually if you listen hard it makes a massive difference to people's lives and healthcare professionals can make a massive difference i mean i think we've all heard accounts of where you know a timely and good intervention from a healthcare professional has made all the difference actually somebody with osteoarthritis so i think that for me is it matters and it matters more than you realize yeah so don't don't take this lying down and be proactive about getting out there and and doing something about it yeah regina in closing is there any one piece of advice knowledge or wisdom that you'd like to give to people out there with osteoarthritis uh have you ever watched a movie called mary poppins so a damn movie and it's a book so i left the sentence that everything is possible even the impossible i really i kind of like don't give up so everything is possible yeah wonderfully positive advice i can see you flying away with the umbrella right now george any feedback thoughts advice it's similar in in the sense that i think all the research that we've been involved in suggests that the future pain and disability etc is still modifiable no matter where you are actually on this spectrum this idea that somehow the damage is done and you've got this thing in the future set is is wrong actually i think all of the research suggests that it's still modifiable and that's where i think a lot of the positive hope comes from that's a really great way to finish very thoughtful advice and i just want to close in thanking both of you it was wonderful to have a chance to chat to you and gain your insights and thoughts on a really really important topic which i'm sure our listeners will love so thank you so much thank you thank you i'll go away and mock up that billboard [Laughter] that is all for this episode of joint action if you like what you hear and want to support us please rate us on your favorite podcast platform alternatively visit the website www. jointaction. info to post a question donate to our research or send us some feedback between now and next time please do take care of yourself stay strong and stay active thank you so much for listening thanks for listening to joint action with david hunter if you like our show and want to know more check out www.

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