Month: July 2024

What is ‘Realistic Medicine’ ?

All around the world, health care systems are talking about realistic medicine in some form or another. The words are not the same, but there is a common theme. In Canada, and in the UK, the movement is called ‘Choosing Wisely’ and in Wales, the conversation is about ‘Prudent Healthcare’. The ‘Choosing Wisely’ movement started in 2012, and is now internationally relevent, with over thirty countries and eighty specialist organisations engaged in the initiative.

At the heart of this new era in modern health care is the key idea that, just because we can do something, doesn’t mean it is right, ethical or reasonable to do it. Moreover, the goals of care for any particular patient should be the key priority against which any course of action should be measured.

Patients need trusted information that helps them understand that more care, more technical and intensive investigations and treatments are not always better. Some tests and treatments do not necessarily lead to improved health, or achieve what matters to them.

A patient’s tale. Mr M is a fictional patient on a remote island in the Hebrides. He is 84 and lives in the home he was brought up in. He is quite lonely; many of his generation have died in recent years, and surviving friends are generally not fit to drive, in residential care or in poor health. He has advanced prostate cancer, chronic kidney disease and poor mobility due to painful osteoarthritis. He is frightened of dying away from his people. When he develops urosepsis, he is admitted to the community hospital a few miles away.

Should he be flown by air ambulance to a bigger hospital where he can be treated with gentamicin, and cared for in a high dependency unit? This level of care cannot be provided in the community hospital. Or should he be managed by a GP without gentamicin?

Mr M’s goal is not to leave the island for health care, as he would prefer to die locally, so the decisions about care are about meeting this goal. The GP, the lead nurse and Mr M discuss his goals, and then the risks and benefits of treatment options. He survives this infection, and his goals are recorded in his clinical record. He is relieved that his fears are acknowledged and heeded, and he feels supported in his decision.

This movement requires excellent communication with patients and the public, so that they can be fully engaged in decisions about their care, and empowered to set the goals of that care. These conversations can be intense, personal and emotional, if they are to be really meaningful.

This does not just change individual discussions between one clinican and a patient, it informs the mindset of the whole healthcare system. Public involvement in this discussion is growing. Some national consumer groups, patient organisations and disease-specific groups are adopting these ideas, so that patients feel empowered to begin the conversation with their clinicians.

Realistic medicine should be a core part of health literacy, whatever you call it. As equal partners, doctors and patients can both ask for and engage in these conversations, however intense they are, because they are a fundamental part of providing good health care.

Words that disempower patients

Linguistic determinism is a concept that says that the language you use shapes the way that you think. The words we choose can change the way we limit and frame understanding, knowledge and ideas, and alter memory, categorisation, and perception. It is no surprise, then, that it affects the relationship between doctors and patients.

I have kept an article from the British Medical Journal from April 2022 to reread. It discusses the use of medical language. The authors state that the medical profession, in using elitist and outdated language, ‘casts doubt, belittles or blames patients, and jeopardises the therapeutic relationship…’

Using language in a way that disempowers patients is endemic. I’m sure, as a younger doctor, and copying the phrases of my senior colleagues, it helped me overcome imposter syndrome. This sort of language is pervasive, and using it makes you ‘one of the team’.

One example describes the situation where the clinician is struggling to make sense of the patient’s story within the clinician’s attention span. The patient is described as being ‘a poor historian’ when their narrative account of their symptoms does not meet the expectations of the clinician. It is the clinician’s duty to listen, to understand their story, concerns and expectations. Our skill as doctors, nurses, or other health professionals, is to ask the right questions, to listen carefully and to recount the clinical history accurately.

Other examples, with alternative words:

  • Presenting complaint – reason for attendance – ‘complain’ has negative connotations.
  • Ceiling of care – goals of care – ‘ceiling’ implies a limit to the treatment on offer.
  • Not compliant – this phrase is used when the patient did not follow instructions, but there is usually no mention as to whether the patient had agreed to the initial plan. We could write ‘barriers to adherence include …’
  • Did not attend – barriers to attendance – some patients really struggle with transport, mental health, organisational skills; by identifying the barriers, we can help patients access care.
  • Patient claims – patient reports – ‘claim’ implies that the patient is not being truthful.
  • Patient denies – patient did not experience – ‘deny’ implies a lack of truthfulness, of withholding information.
  • Patient refused – patient declined
  • ‘Has the patient been consented?’ – in this example, the patient is a passive recipient of information, no record of what the patient has understood and retained about a procedure.
  • Substance abuse – has a substance use disorder – the first phrase is associated with patient blame.

Patients can report feeling child-like in clinical settings. For example in a diabetic setting, blood sugars can be ‘good’; does the opposite imply that the patient has been naughty and bad? Some patients recount feeling as if they have been scolded for their poor outcomes, or ‘treatment failure’.

Every so often, I come across another phrase that is part of routine clinical discussion, and discover a more human, collaborative way of putting my view across. I hope to find ways of validating the patient experience, and allowing patients the opportunity to collaborate in creating their care plans.

The key messages from the article:

  • Some commonly used language in healthcare characterises patients as petulant, passive, or blames them for poor outcomes.
  • Such language negatively affects patient-provider relationships and is outdated.
  • Clinicians should consider how their language affects attitudes and change as necessary.
  • Changing our language to improve trust and support shared decision-making is unlikely to harm patients.
  • Better use of language may help us to reach more patient-centred and realistic care plans.

Linguistic determinism https://en.wikipedia.org/wiki/Linguistic_determinism – The concept that language and grammar affect the way we limit and frame understanding, knowledge and thought, for example, memory, categorisation, and perception.

The article by Caitríona Cox and Zoë Fritz was published in the BMJ on 30th April 2022, (you can read it here: https://www.bmj.com/content/377/bmj-2021-066720)