‘Doctor knows best? Improving clinical conversations’

‘Personal Views on Healthcare in Wales’

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Paul Myres, Royal College of General Practitioners

 

Doctors retain positions of power and influence. We are used to deciding what is probably best for our patients. We pride ourselves on listening to what patients are saying to us, using our skills to make diagnoses and producing management plans. We like to think we are skilled in engaging with our patients and acting in their best interest. We are trying hard to be more open with patients when we know care has been suboptimal under our duty of candour. We are expected to give full information about risks, benefits and likely outcomes when seeking consent for invasive procedures following the Montgomery ruling.

 

We are inundated with guidance on effective management and treatment strategies based on evidence. But how robust is that evidence, how relevant is it to the individuals we are dealing with and how well do we adjust our management plans to the circumstances of the individuals we are seeking to help? How well do we understand what is important to them rather than what is clinically “correct”.

 

The Wales Academy was asked by the previous Minister for Health Mark Drakeford to lead the Choosing Wisely movement in Wales. We have been looking hard at what this means for clinicians and patients. It seeks to reduce the number of inappropriate tests and treatments done to patients to avoid harm and waste. One of the reasons that inappropriate tests or treatments are instigated is that the patient has not been fully involved in the making the decisions about their care. Shared decision making has been shown to increase satisfaction and outcomes and reduce harm.

 

Don’t we do that already? Not according to a European patient survey which has found that only half of respondents feel they are involved in decisions made about their healthcare and this has been consistent over the last three years. Yes, many of us are giving better information to patients about their condition and treatments planned but we don’t always describe all the risks involved or the potential unreliability of test results. We may explain what we recommend but do we give all the options, do we always consider that avoiding treatment may meet the patient’s wishes better than “doing more” Two international maxims are “Doing less is more” and “Don’t just do something, stand there”.

 

Of course many tests will determine the cause of problems and inform appropriate treatment. Many treatments make life better. Clinicians have long and detailed training and are tested and monitored. Most clinicians build up good experience in how to apply their knowledge and experience for the benefit of patients. However, tests and treatments may sometimes do more harm than good – potentially leading to uncertainty and worry, or detrimental side effects.

 

So how can we do it better? Is it feasible to regularly discuss the value of treatments and make shared decisions? Can we ensure reliable and valid information is available for patients and clinicians regarding agreed interventions of low value?

 

Shared decision making means that both the clinician and the patient (and/or carer) are involved in reviewing options, agreeing what is a good outcome for the patient and agreeing jointly on a management plan. Such a process also implies a shared responsibility for that decision and an acceptance or at least an understanding of the risks and likely benefits of the actions proposed.

 

The patients is the expert in their life, family, relationships and their own hopes and fears but how far is the patient an expert in their own body. The clinician is an expert in the way the human body functions and malfunctions but also has to be aware of the high level of uncertainty in medicine.

 

How equal can we make the relationship? Does shared decision making mean each person has an equal say? In our NHS the doctor has the final say regarding access to investigations and treatments and the patient has the final choice in deciding whether to accept or cooperate with the treatment or to attend for an investigation. The doctor usually understands the system better and is in familiar territory. The patient is likely to be outside their comfort zone and feeling anxious. It will be easy for the traditional relationship of “doctor knows best” to prevail.

 

We can still try to reduce the imbalance in favour of genuine shared decision making. It requires both sides to be honest and open in what they say they want, need or can offer. Doctors need to be more honest about the strength (or lack) of evidence for a particular action and to do that in a way that inspires confidence rather than suggesting they lack expertise. Patients in turn need to be clearer as to what they expect and be as clear as possible about their symptoms, understanding and fears. Both need to trust the other to be acting in the best interests of the individual but both also need to be aware of what is available and can be funded. Maybe we need to respond to (not necessarily comply with) the patient’s wants before we can talk about needs.

 

Patients need to be more confident in asking searching questions in an open but non demanding way – not always easy if they don’t have the literacy or verbal skills or fear that treatment will be denied. Empowering patients means others letting go of some power. Doctors need to let go of some responsibility, acknowledge that they don’t have all the solutions and encourage patients to take more responsibility.

 

 

Choosing Wisely Wales will help patients and their clinicians to choose together the right care for each patient.

 

Aims of the programme

 

  • Embed a broad culture change in healthcare where clinicians and patients regularly discuss the value of treatments and make shared decisions.
  • Ensure reliable and valid information is available for patients and clinicians regarding agreed interventions of low value, i.e. where there is a low chance of a beneficial outcome.
  • Enable participating professional health organisations such as the health professional colleges and societies, to produce with patients lists of commonly used treatments/interventions whose necessity should be questioned.
  • Encourage local clinical teams to use shared decision making skills in consultations and adopt / select locally relevant interventions of low value to concentrate on when applying shared decision making.
  • Reduce harm to patients caused by inappropriate use of tests or interventions. Support will be given to patients to help them make decisions about their care, avoiding tests and treatments which are unlikely to benefit them. Reliable accessible information will also be provided or signposted to support open and honest clinical conversations, helping clinicians and patients to apply that information to local and personal circumstances.
  • Choosing Wisely Wales is a clinician led movement in partnership with patients and public health. We are looking for local champions from all disciplines

 

Further Information

Website: Choosing Wisely Wales

Email: Paul.myres@wales.nhs.uk

Twitter: @ChoosingWiselyW

Facebook: Choosing Wisely Wales

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