“Managing Chronic Diseases Requires Cooperation” – Geraldo Krasi Talks About the Importance of Trust in the Doctor-Patient Relationship

Geraldo Krasi is a newly appointed family doctor at the Duhanas clinic in the Velabisht Health Centre, known for his expertise and dedication during training sessions supported by HAP, particularly in his role as a facilitator for Peer Groups.

Could you briefly describe your role in identifying and providing healthcare for patients with non-communicable diseases (NCDs)?

I work as a Family Doctor for all age groups at the Ura Vajgurore Health Centre, in the “4-Shtatori” health post. For the past three years, I have been providing healthcare to about 2,600 residents in total, some from the neighbourhood of the same name and others from the villages of Konezbaltë and Pashalli. There are around 350 chronic patients, most of whom are affected by one or more non-communicable diseases such as hypertension (HT), diabetes mellitus (DM), dyslipidaemia, bronchial asthma, and COPD. These patients are mainly treated with reimbursed medications and typically receive prescriptions within a two-month timeframe. This period also corresponds to their follow-up visits at the health centre. A significant part of my work involves monitoring residents who undergo the Basic Medical Check-Up, where conditions like HT, dyslipidaemia, or DM may be discovered incidentally. During the consultation for check-up results, these individuals seek more information about their condition and treatment options.

What do you think are the main challenges in delivering healthcare services in your community?

The challenges can be summarised as follows. For patients newly diagnosed with an NCD, the difficulties may include: adapting to the therapy and lifestyle changes; more frequent follow-ups initially to assess treatment effects and disease control; lack of resources, such as glucose test strips for routine glycaemia checks and necessary equipment and kits for biochemical analyses at the health centre; reimbursable medications, or more precisely, the limitations of the Drug List and regulations, which newly diagnosed patients often find difficult to understand. For me as a family doctor, a challenge is the large area of the territory I cover with services, and recently, the increasing number of elderly people who live alone. These are the same patients who have more than one NCD and need more frequent follow-ups with specialist doctors, have multiple needs, and often social problems that coexist with health issues, all of which pose difficulties for the Family Doctor and Nurse, as they are closer to the patient than other institutions. I would emphasise that the social problems to be solved are not within our control, but they complicate our work.

How would you describe the relationship between medical staff and the community? Do citizens trust the medical staff? Do they come to you for advice and guidance?

From my perspective, the relationship with the community is very good, although there are always problematic patients or family members. The engagement of medical staff is undoubtedly high, maintaining professionalism and aiming for the well-being of the patient. It should be noted that the highest trust in the medical staff comes from chronic patients. This is because building a trustworthy relationship takes time, and chronic patients, over time, have seen the medical staff’s commitment to them. Patients come for advice and guidance and seek help in managing their condition. When they have acute issues, they often refer to the nurse or doctor, which demonstrates the trust they have in the medical staff, something that gives us satisfaction in our work.

What factors do you think influence the quality of healthcare services provided to the community, especially concerning NCDs?

Some factors that come to mind are: the workload of the family doctor and nurse; the large number of daily visits, resulting in less effective time for each visit; the organisation of work at the health centre, where although there are several nurses with specific roles, none have a clear role in patient education, which is particularly problematic in health posts with small spaces where the educational aspect that could be delivered by the nurse is almost missing, as the doctor and nurse share the same space; the ever-increasing tasks assigned to the family doctor and nurse concerning the area they cover, which often take time away from managing patients with NCDs, such as involvement in eye screenings at schools, completing documentation for the increasing number of reports for central directories, etc.

How valuable do you think the training on implementing NCD protocols has been? How has this training affected clinical practice and care for patients with NCDs?

The training has been very valuable. It has updated the knowledge of medical staff and, in a way, standardised the work of medical staff, even though we work in different clinics. The improved knowledge has increased the professionalism of the medical staff. The implementation of treatment protocols ensures that patients now receive the same care, avoiding variations due to the individual preparation of staff members or differences between urban and rural locations.

What difficulties do you think there might be in implementing these protocols in daily practice?

I believe the difficulties are primarily related to the patients, their engagement in non-medication treatment of certain diseases, and their regular intake of medications. There will also be challenges for staff who will need to spend more time educating patients, changing previous routines in the management of NCDs, and finally dealing with issues related to reimbursable medications or the limitations that family doctors face in altering medication types or doses without first referring the patient to a specialist.

What kind of support do you think would be necessary to ensure the successful integration of protocols in primary care?

A great deal of support has come from HAP, providing support materials that facilitate the implementation of treatment protocols and better documentation of care in patient records. Additionally, the tools in the doctor’s kit help better manage patients. I think it would help if some doctors who have successfully integrated these protocols into their daily practice could share their experiences, and these exchanges could happen systematically at the health centre.

How do you plan to engage and educate patients about managing their respective NCDs within the framework of these protocols?

I think patient engagement depends primarily on delivering information in the most professional, accurate, and convincing manner, but also in a holistic and empathetic way. I believe it’s essential that the patient understands that the medical staff is providing this information because they are important, and valuable, not just because of the specific disease they have, but as a whole human entity. Initially, I think this is how patient trust is built, making it easier to engage them in managing NCDs. Of course, it’s important not to overlook information about the disease’s progression, such as the complications it brings to the patient’s body, but also the benefits they can gain from lifestyle changes and disease control. All of this should happen gradually, during regular follow-up visits, where patients are suggested and asked to change their lifestyle step by step. I believe a radical and immediate change can stress the patient and does not bring real long-term benefits.

Have you noticed any changes in the patients’ health conditions and quality of life since the implementation of these protocols?

I would definitely say yes! For patients who have cooperated well in managing their NCDs, the implementation of protocols has led to a noticeable improvement in their health condition and, later, in their quality of life. With better follow-up, updated knowledge, and the implementation of protocols, patients have a clearer understanding of what they need to do. The patients themselves report significant improvement during follow-up visits, and laboratory tests confirm either improvement or the maintenance of their chronic condition under control.

Do you think there is room for improvement in these training sessions? In which areas?

The training sessions have been a great help for the medical staff. Here, I would emphasise the importance of involving the doctors and nurses who manage these specific chronic diseases in adults in their daily practice in the Training of Trainers and Peer Groups on NCD protocols. I think it would positively impact the practical implementation of the protocol if, after the training, for example, a nurse could participate in the regular working day of a doctor who has completed the training. This way, the nurse is more likely to put her knowledge into practice right away.