I’m a member of a PBSGL group. We are very small and select, because I work on an island in a small practice, and there aren’t that many GPs in the area. I love our group. We have great rapport, our discussions are free-ranging and we get to eat some great cheese.
Because I am very interested in bringing Realistic Medicine into the way we co-produce health with patients, I thought that this would be a good module to work through.
I was a bit disappointed.
At the heart of Realistic Medicine, there are a number of concepts. One is the balance between evidence-based medicine and the expectations and wishes of patients. Sharing clinical risk is in there, as is the redesign and presentation services in a way that puts patient need first. Reducing unwarranted variation, harm and waste is important.
I was a bit underwhelmed by this module – it could have been a module on multimorbidity and geriatrics, and the level of debate that the cases raised was well within our current scope of practice.
The three cases were all concerning elderly patients, and the tension between evidence based medicine, frailty and multimorbidity. While they were true to life and interesting, at the end of the session we felt we’d learnt more about community services for older patients, rather than about realistic medicine.
The background reading later in the module was of much greater value, and covered many of the concepts of realistic medicine. However, we found it tricky to include this material in the discussion of the cases.
In short, we did not feel that this module stretched our understanding and learning. Maybe that is our failing, rather than that of the module. Was this more about PBSGL jumping on the ‘Realistic Medicine’ bandwagon?
I read the BMJ every week, and tag the articles that might influence my practice. This time, the article that caught my eye was about falls: https://www.bmj.com/content/364/bmj.l880. The summary – assessment by an occupational therapist, and making your home safer works well in patients at high risk of falling.
We’ve all been there, talking to patients about their rugs, the hazardous route round the bed with all the slippers in the way. Patients like the way they live, and just handing out advice doesn’t always make a difference.
This article has a great wee box on the co-production of safety at home, how to make very real improvements. The language is quite technical, so I have paraphrased this below. I’m so excited about it that I may well make a waiting room display on the subject.
If you are 65 or older and live at home, your risk of falls in the future is higher if you’ve had a fall in the last year, use a mobility aid, need help with basic activities, take medications that might make you sleepy, or if you are worried about falling
An assessment of where you live by an occupational therapist could reduce your risk of falls
The assessment involves a visit from the occupational therapist, who will recommend changes to tasks and your environment. These suggestions aim to reduce hazards and improve your independence and safety.
The occupational therapist may also suggests gadgets and technology to improve your safety at home, such as an emergency buzzer.
Occupational therapists typically ask you to identify what you think puts you at risk of falling, and you jointly problem-solve and agree on solutions.
This weekend’s reading has included this book. In fact, I haven’t read anything else. The last two chapters in particular explore the relationship between doctors, their patients, between patient autonomy and taking clinical responsibility.
Atul Gawande is a surgeon and writer based in Boston, Massachusetts. He has written several very popular books about the praactice of medicine, as well as delivering four Reith lectures for the BBC in 2014.
This is his first book, published in the UK in 2002. There are fourteen essays, grouped into three sections. The first deals with fallibility and error, and the second looks at the mystery of medicine.
The final four essays discuss how we manage uncertainty in medicine, the interface between clinical evidence and human decisions. The penultimate essay is entitled ‘Whose body is it anyway’. In this essay, he discusses some of the core issues of realistic medicine, fourteen years before Catherine Calderwood coined the phrase. In truth, consent and patient autonomy are not new, but having a banner under which to explore these themes has been powerful.
He discusses the gap between what patients want and what they hope for. His writing is straightforward, and his arguments are illustrated by cases, the stories that hook clinicians into the debate. He describes how honest clinical discussions allow patients to understand what is happening, and take their share in the decisions.
In his own words: ‘Just as there is an art to being a doctor, there is an art to being a patient. You must choose wisely when to submit and when to assert yourself. Even when patients decide not to decide they should still question their physicians and insist on explanations… You do the best you can, taking the measure of your doctors and nurses and your own situation, trying to be neither too passive nor too pushy for your own good.’
‘Where many ethicists go wrong it is in promoting patient autonomy as a kind of ultimate value in medicines rather than recognising it as one value amongst others. Schneider (The Practice of Autonomy) found that what patients want most from doctors isn’t autonomy per se; it’s competence and kindness. Now kindness will often involve respecting patient autonomy, assuring that they have control over vital decisions. But it may also mean taking on burdensome decisions when patients don’t want to make them, or guiding patients when they do.’
‘Even when patients do want to make their own decisions there are times when the compassionate thing to do is to press hard: to steer them to accept an operation or treatment that they fear or forgo one that they pinned their hopes on. Many ethicists find this line of reasoning disturbing, and medicine will continue to struggle with how patients and doctors ought to make decisions. But, as the field grows ever more complex and technological the real task isn’t to banish paternalism; the real task is to preserve kindness.’
The eternal balance between clinical evidence, being clear about outcomes and chance, giving patients the chance to influence the chances that they have and the treatments that they receive.
It has been a long time since I blogged, but not for lack of ideas, more a deluge of concepts and ideas, combined with the ever-present day job.
Today, I read an article in the BMJ, (click here to read it yourself) and it has lit a slow fuse. The article is about the ultimate patient engagement, where individuals with a condition create solutions that revolutionise care.
Patients really understand what it is like to live with their condition, to come to terms with how it will affect their living and their dying. Patients who have been given the opportunity to understand what their condition is, and how it will progress, patients who have time to focus on their own solutions, these are the people who are coming up with the solutions that healthcare industry had never considered.
This is the ultimate patient engagement, where patients have found what is on offer doesn’t meet their needs, where the risks are unacceptable, or the outcomes just not good enough.
The inventions covered include a new type of surgical prosthesis for aortic root problems in Marfan’s disease, a smart ileostomy bag that tells you when it needs attention, an app to self-manage repeat prescriptions and medication compliance, another IT solution that uses CBT to improve sleep, an physiotheraby device for hand rehabilitation.
The people behind these innovations are all persistent, have really understood the issues they are trying to solve, and have been steadfast in their pursuit of developing and sharing their ideas for the good of people like themselves. For several, they comment that it has been a long, frustrating process. Tal Goldsworthy, the inventor of the aortic root device, comments ‘If I had known it was going to be this hard, I really wouldn’t have bothered’ – but never the less, he has devised a safer alternative to aortic root replacement, and 200 patients have been fitted with his device.
What these innovaters have found in their paths to success has been a willing clinical supporter. In general, one of the key hooks is being able to show that the innovation makes for better care without adding complexity.
The message – ‘if you are a doctor who believes in the technology, then two words are key: be brave’. It is so much easier not to do something, but with courage you can help technology to really grow’. Patients have their own lives to enhance, and that is a powerful motivator, but we need to be there as clinicians to make new ideas work.
In the most recent annual report from the Chief Medical Officer for Scotland, Dr Calderwood discusses the need to move towards a shared approach to clinical decision-making. Are we not already doing this? The evidence says not.
NHS surveys tell us that patients value highly the opportunities to discuss their care, the options open to them, and being involved in the decisions that shape their management. A survey undertaken by the Citizens’ Panel showed that while 92% of patients felt comfortable about asking their doctor about treatment, only 67% did so. Similar percentages were recorded for discussing risks and benefits. Why is there a gap? Patients report that the willingness of doctors, of how busy they appear to be, inhibit these discussions.
If we are to change our culture further (and it has already changed over the last fifty years) then we need to focus on how we enable these conversations. How often do we interrupt patients when they are talking? As well as restricting their narrative, it limits their expression of what is of concern. It emphasisis the agenda of the clinician and the pressures on their time. This needs to be more than tokenism, we need to really dig deep and learn better ways to do this. Having a good framework in which to conceptualise these conversations is important. One such structure is the three talk model.
I also think that, as well as listening, and leaving space for debate and questions about management, we can coach patients to ask for better information. Some of this confidence comes from health literacy. Some comes from having the right words, the right questions to ask of clinicians as they leave our primary care consulting rooms and are passed on to secondary care colleagues, to other clinical teams.
This is where the five questions come in. The five questions were drafted by Choosing Wisely UK, which is part of global initiative to improve conversations between patients and their clinicians. Five boards piloted the use of the five questions, encouraging people to ask clinicians about their management plans. Having the questions written down enables patients to take first steps in these discussions. The questions aren’t going to change the world, but they can empower patients to start these important conversations.
I have displayed these questions in practice leaflets, on the noticeboard in the waiting room, on lanyard cards, on signposting cards and on the practice website. I don’t know how well I would do with answering all of the questions all of the time. However, as well as providing concrete examples for patients, this produces an environment, a culture where patients are expected to discuss their care. This message is as powerful for my colleagiues as it is for patients.
A wise friend of mine, Dr Maria Duffy, commented that these questions appear very clinically orientated. They do not explicitly promote discussions around the social determinants of health. She works in Pollok and is a GP trainer as well as a GP partner. She is part of the Deep End group, practices who look after patients in more deprived areas, where there are higher proportions of patients whose social and economic background has a big influence on their health.
She would add:
Is going to the doctor the best way to address my problems?
What is there that I might change myself that would help?
How much do I expect to achieve by seeking a clinical solution?
While these questions do not focus on a shared approach to clinical decision-making, they encourage patients and clinicians to think outside the clinical box, to imagine other ways of tackling life’s problems.
However, it is not enough to parachute in to our surgery with the cards and the posters. The most important next step for me is to ensure that my colleagues understand the scope of what I am doing, that patients are engaged in the project, and that any practical top tips are spread to other clinical areas.
As well as being a GP, I have been working in secondary care as a GP with a special interest in Dermatology. Around five years ago, I was feeling very annoyed with one of the practices that refers to the dermatology clinic. Patients were attending for review without having tried the treatment that I had suggested.
The dermatology clinic is usually rammed, and these appointments were adding unnecessary pressure on the clinic, wasting patients time, as well as adding a longer burden of ill-health due to skin disease. Nobody was happy.
I could have written to the practice and had a strop, but the practice involved was struggling to recruit partners or salaried GPs. They were relying on locum cover, and there didn’t seem to be an end in sight. In addition, other patients in other practices didn’t always seem to understand their treatment plans.
An aside here: most patients with chronic dermatological conditions have complex treatment regimens. This could include a pre-washing emollient, a soap substitute, a moisturiser, then a topical treatment, to be titrated up or down, and tapering to other treatments. Very few patients and GPs manage to get this all down at the first attempt.
I started writing my clinic letters direct to the patient with a copy to the GP, with consent. Nobody turned me down. The best responses were from relatives of patients with dementia, where a written care plan was useful for the team of carers. At the clinic, patients were advised to check with their practice for their prescription when they received their copy letter.
I didn’t do this as a proper improvement project, I didn’t measure follow-up outcomes, patient satisfaction, and I didn’t have a ‘spread’ plan. However, the feedback was immediate, and positive. GPs were in favour: they no longer have to contact patients to check up on new prescriptions. Patients were in favour, finding it helpful to have the treatment plan written down in the letter. Relatives were in favour, having a documented plan to follow. The secretary confirms that there is no additional work in doing the letters this way.
After 3 years of doing letters this way, I’m beginning to see other clinicians trying this out. Patients bring their letters to GP consultations, ready to discuss their treatment as more equal partners. I have been asked to advise other clinicians about how to structure their letters.
The biggest and best outcome is patients as equal participants in their treatment, and communication about their health. It is a culture shift, and it is gradual, and I am part of it.