Counselling of a Medication

Counselling of a Medication

Your role: You are the doctor in the rheumatology outpatient clinic

Problem: Discussion regarding lack of adherence to methotrexate

Patient: Mrs. Linda Stevens, a 55-year-old woman

Please read the scenario printed below. When the bell sounds, enter the room. You have 10 minutes for your consultation with the patient/surrogate. You may make notes if you wish. Where relevant, assume you have the patient’s consent to discuss their condition with the relative/surrogate.

Scenario:

You have been asked to see this patient by her family doctor. The patient was diagnosed with rheumatoid arthritis 3 years ago, and after initial treatment with NSAIDs and steroids showed inadequate response, methotrexate was prescribed. Despite the medication, her disease activity score (DAS28) over the last 6 months has been high, indicating poor control of her condition. On reviewing her medication history, it's noted that she has not been regularly taking her methotrexate. Her recent blood tests including liver function tests, complete blood counts and kidney function tests, were normal.

Your task is to discuss with the patient why she is not taking her medication, to emphasise the importance of reasonable disease control with methotrexate, and to answer any questions she may have.

DO NOT EXAMINE THE PATIENT DO NOT TAKE A HISTORY

Any notes you make must be handed to the examiners at the end of the station.

Conducting the Station: A Step-by-Step Guide

Introduction: Greet Mrs. Linda Stevens and confirm her identity. Explain your role as the doctor in the rheumatology outpatient clinic and the purpose of the meeting.

Understand Her Perspective: Start with open-ended questions to understand why she is not taking her methotrexate. She might be facing issues such as side effects, forgetfulness, fear of long-term use, or lack of understanding of the importance of the medication.

Reinforce the Importance of Medication: Explain the importance of methotrexate in managing her rheumatoid arthritis. Emphasise that controlling the disease can prevent joint damage, reduce pain, and improve her quality of life.

Discuss Potential Risks: Discuss the potential risks of poorly controlled rheumatoid arthritis, such as joint deformities, pain, loss of function, and increased risk of cardiovascular disease.

Address Her Concerns: Answer any questions she may have about methotrexate. If she is concerned about side effects, reassure her that she is being closely monitored and that any problems can be managed effectively. If she is concerned about long-term use, discuss the benefits versus risks.

Develop a Shared Plan: Work with Mrs. Stevens to develop a plan for taking her medication consistently. This might involve setting reminders, managing side effects, or seeking additional support.

Check Understanding: Ask Mrs. Stevens to repeat back her understanding of the information you've provided to ensure she has understood.

Follow-Up: Schedule a follow-up appointment to monitor Mrs. Stevens' progress and adjust the plan if needed.

Conclusion: Thank Mrs. Stevens for her time, encourage her to contact the clinic if she has any further questions or concerns, and reassure her that you are there to support her.

In young patients, you need to discuss family planning, as methotrexate can impact fertility and pregnancy.