Tag Archives: doctor patient relationship

Why don’t people take medical advice?

Significant proportions of people walk out of doctors’ clinics and disregard or fail to act on the opinion offered.  What practitioners can do to help is to review their communication style. As Bungay Stanier has suggested it can’t be assumed that the first thing the person mentions is what is bothering them the most. Bungay Stanier’s suggested questions will reduce the rush to action. A rush that fails to identify the issue that the patient may feel is a greater priority than hypertension or diabetes.

I summarise the issue in this video:

 

Picture by Sergio Patino

What is said to people when drugs are prescribed for life?

Every day doctors suggest that one or other of their patients have to take medication for life. Hypertension, diabetes and certain deficiencies are among the many conditions that may benefit from taking medication longterm. On the other hand, many people reject this advice or take the prescribed drugs only sometimes. Ultimately the decision to accept treatment is for the person with the condition to decide. How can the advice be tailored so that the person is making an informed decision?

BACKGROUND: ‘Concordance’ has been proposed as a new approach towards sub-optimal medication use; however, it is not clear how this may be achieved in practice. AIM: To develop a strategy for understanding sub-optimal medication use and seek concordance during primary care consultations. DESIGN: A developmental qualitative study using a modified action research design. SETTING: Three Scottish general practices. METHOD: Patients using treatment sub-optimally and having poor clinical control were offered extended consultations to explore their situation. Their authority to make treatment decisions was made explicit throughout. Clinicians refined a consultation model during ten ‘Balint-style’ meetings that ran in parallel with the analysis. The analysis included all material from the consultations, meetings, and discussion with patients after the intervention. RESULTS: Three practitioners recorded 59 consultations with 24 adult patients. A six-stage process was developed, first to understand and then to discuss existing medication use. Understanding of medication use was best established using a structured exploration of patients’ beliefs about their illness and medication. Four problematic issues were identified: understanding, acceptance, level of personal control, and motivation. Pragmatic interventions were developed that were tailored to the issues identified. Of the 22 subjects usefully engaged in the process, 14 had improved clinical control or medication use three months after intervention ceased. CONCLUSIONS: A sensitive, structured exploration of patients’ beliefs can elucidate useful insights that explain medication use and expose barriers to change. Identifying and discussing these barriers improved management for some. A model to assist such concordant prescribing is presented. Dowell et al BJGP

I summarise the issue in this video:

https://youtu.be/xFQ2kVOMS64

Picture by Victor

The healthcare experience must change

The person who believes they have a problem must be fully involved in the options offered for treatment if healthcare is to result in the best outcomes. Research and experience suggests that may not always be the case:

OBJECTIVE: To evaluate hospitalized patients’ understanding of their plan of care.

PATIENTS AND METHODS: Interviews of a cross-sectional sample of hospitalized patients and their physicians were conducted from June 6 through June 26, 2008. Patients were asked whether they knew the name of the physician and nurse responsible for their care and specific questions about 6 aspects of the plan of care for the day (primary diagnosis, planned tests, planned procedures, medication changes, physician services consulted, and the expected length of stay). Physicians were interviewed and asked about the plan of care in the same fashion as for the patients. Two board-certified internists reviewed responses and rated patient-physician agreement on each aspect of the plan of care as none, partial, or complete agreement.

RESULTS: Of 250 eligible patients, 241 (96%) agreed to be interviewed. A total of 233 (97%) of 241 physicians completed the interview, although sample sizes vary because of missing data elements. Of 239 patients, 77 (32%) correctly named at least 1 of their hospital physicians, and 143 patients (60%) correctly named their nurses. For each aspect of care, patients and physicians lacked agreement on the plan of care in a large number of instances. Specifically, there was no agreement between patients and physicians on planned tests or procedures for the day in 87 (38%) of 229 instances and in 22 (10%) of 220 instances. Complete agreement on the anticipated length of stay occurred in only 85 (39%) of 218 instances.

CONCLUSION: A substantial portion of hospitalized patients do not understand their plan of care. Patients’ limited understanding of their plan of care may adversely affect their ability to provide informed consent for hospital treatments and to assume their own care after discharge. O’Leary et al

Here is my summary of this topic:

Picture by Bruno Dumont

Triggering better health outcomes

The first piece of data we collect in healthcare is: date of birth. Could it be used to trigger better habits?

50th birthday bashes have overtaken 21st celebrations as 50 now considered the “peak” age to throw a party, sales figures for cards and party paraphernalia show.

Sales of 50th birthday cards have for the first time eclipsed the number of 21st birthday cards sold, according to data from Clintons, the UK’s biggest cards retailer.

With 50th birthdays now leading on the birthday league table and accounting for 16 per cent of all card sales, 21st birthday cards now make up 14.1 per cent of all cards sold. Katie Morley. The Telegraph Oct 2017

I explore the possibilities.

Picture by synx508

Improve patient experience to deliver better results

Joe and Brenda are now in their 60s they have a number of chronic healthcare problems some of which will put them at risk of life limiting pathology (hypertension) and others detract from their quality of life (low back pain). Everyone involved in providing healthcare to this couple wants the best for them. Best case scenario Joe and Brenda are satisfied every time they consult their doctor and improve from whatever ails them.  It is also better if their use of the healthcare resources is minimised. But what predicts that outcome?

In 2001 the BMJ considered the issues. Paul Little and his colleagues approached three local practices that served 24 100 patients. They invited consecutive patients attending the surgery to participate. All patients able to complete the questionnaire were eligible. 661 participants completed a questionnaire before their consultation in which they were asked to agree or disagree with statements about what they wanted the doctor to do. A questionnaire after the consultation asked patients about their perception of the doctor’s approach. Both questionnaires were based on the five main domains of the patient centred model: exploring the disease and illness experience, understanding the whole person, finding common ground, health promotion, and enhancing the doctor-patient relationship

The post-consultation questionnaire included items about the reason for consultation and a positive and definite approach of the doctor to diagnosis and prognosis as well as sociodemographic details, the short state anxiety questionnaire, number of medical problems, and current treatment. The team also included questions relating to important patient related outcomes from the consultation: enablement (six questions about being enabled to cope with the problem and with life), satisfaction (medical interview satisfaction scale), and symptom burden (measure yourself medical outcome profile, which measures the severity of symptoms, feeling unwell, and daily restriction of activity). Patients were followed up after one month with the measure yourself medical outcome profile, and the team reviewed the medical records after two months for reattendance, investigation, and referral.The outcome measures of interest were patients’ enablement, satisfaction, and burden of symptoms. Factor analysis identified five components:

  1. Communication and partnership (a sympathetic doctor interested in patients’ worries and expectations and who discusses and agrees the problem and treatment);
  2. Personal relationship (a doctor who knows the patient and their emotional needs);
  3. Health promotion;
  4. Positive approach (being definite about the problem and when it would settle); and
  5. Interest in effect on patient’s life.
  • Satisfaction was related to communication and partnership and a positive approach.atisfaction was reduced if expectations were not met for communication and partnership, a positive approach, and an examination but were not affected by expectations of a prescription.
  • Enablement was greater with interest in the effect on life, health promotion, and a positive approach. Enablement was also less if expectations were not met for an examination, health promotion, and a positive approach.
  • A positive approach was also associated with reduced symptom burden at one month. Symptom burden at one month was worse if expectations of a positive approach were not met.
  • Referrals were fewer if patients felt they had a personal relationship with their doctor.If expectations of a personal relationship were not met, referrals were more likely.

From these data and similar results published before and since we can conclude that Joe and Brenda expect the following:

  1. To have their perspective considered by someone who clearly cares
  2. To be examined
  3. To have the impact of the illness on their lives taken into consideration
  4. To be advised when they are likely to feel better and
  5. To receive advice on how to avoid problems in the future

In return they will use healthcare resources less and their symptom burden will reduce. All this might be achieved without major policy reform and can be implemented locally to improve the patient experience and by corollary reduce the strain on healthcare resources.

Picture by Jenny Mealing

First I’ll ask what’s on your mind then I’ll shut up


Every doctor in general practice/family medicine learns about the ‘models‘ of the consultation. My favourite is the Pendleton model. The thinking behind a map of the medical consultation is summarised by  Pawlikowska and colleagues

A fundamental change in medical culture in this area has been the recognition and acceptance of the fact that the way in which health professionals communicate, on all levels, can be enhanced, irrespective of the innate and learned abilities they already possess.

In 2016  Michael Bungay Stanier published The Coaching Habit: Say Less, Ask More  & Change the Way you Lead Forever. This comes at a time when the relationship between doctors and the people who seek their help is changing. With each passing generation, people expect to be actively involved in making choices in healthcare.

Women, more educated, and healthier people were more likely to prefer an active role in decision making…..Preferences for an active role increased with age up to 45 years, but then declined. Livenson

Doctors and the people who consult them will frame themselves as a team. At the same time, the major challenges relate to non-communicable chronic disease. Specifically to encourage people to stop smoking, eat and drink less, exercise more, and to be screened for early detection of malignancies. And for those who succumb to actively manage their chronic illness.

Therefore the interaction between the person seeking advice and the ‘expert’ is more likely to be akin to coaching. Given that people present to primary care with undifferentiated conditions the agenda for the meeting is set by the person who made the appointment. That’s why Bungay Stanier’s practical approach is a significant contribution. If we accept that the doctor is to be the ‘coach’ the author sets the scene in the very first chapter:

Only 23% of people being coached thought that the coach had a significant impact on their performance or job satisfaction. Ten percent even suggested that the coaching they were getting was having a negative effect. ( Can you imagine what it would be like going into those business meetings? ” I look forward to being more confused and less motivated after my coaching sessions with you.”)

The book emphasises that ‘coaching’ is a habit. Something that needs to be valued for three reasons:

  1. To avoid the team members becoming overdependent on the coach.

Building a coaching habit will help your team be more self-sufficient by increasing their autonomy and sense of mastery by reducing your need to jump in, take over and become the bottleneck.

There is already such a concern about over-dependence in medicine. Read Naomi Hartree’s summary ( Helping Patients Avoid Doctor Dependency)

2. To avoid getting overwhelmed.

Building a coaching habit will help you regain focus so you and your team can do the work that has real impact and so you can direct your time, energy and resources to solving the challenges that make a difference.

Being overwhelmed is a recognised problem in medicine.  Read locumstory(Physician Workload)

3. To help people do more work that has impact and meaning.

Coaching can fuel courage to step out beyond the comfortable and familiar , can help people learn from their experiences and can literally and metaphorically increase and help fulfil a person’s potential.

Again this has strong resonance in healthcare specifically because of the limited predictive value of tests or the large number needed to treat. In addition, there is mounting concern about the variation in these outcomes across geographical areas. See John Newton.

The Coaching Habit emphasises seven questions in a specific order. The first question is arguably the most important. Bungay Stanier calls it the kickstart question: ” What’s on your mind?” He justifies it as follows:

Because it’s open, it invites people to get to to the heart of the matter and share what’s important to them. You’re not telling them or guiding them. You’re showing them trust and granting them autonomy to make choices for themselves. And yet the question is focused, too. It’s not an invitation to tell you anything or everything. It’s encouragement to go right away to what’s exciting, what’s provoking anxiety, what’s all-consuming, what’s waking them at 4 a.m., what’s got their hearts beating fast.

This question followed by the space to answer is one that creates the opportunity to find what is really bothering someone. It is not universally common in healthcare. There’s an eloquent summary of the data from Juliet Mavromatis

Why do physicians interrupt? In practical terms, throughout the course of a given day a physician may be tasked with listening to twenty to thirty patient derived histories and with solving difficult problems for each of these patients in a matter of ten to fifteen minutes. This is a tough, if not impossible job. Consequently, once a physician believes that the meat of the story is out there, he or she may respond and interrupt before hearing details that the patient (or colleague) feels are important. In more abstract terms interruption is a communication strategy that reinforces physician dominance in the hierarchy of the patient-physician relationship.

Picture by Allie Hill

The infographic bandwagon rolling in to your clinic

In the wake of her book launch I had the honour to interview Dr. Halee Fischer-Wright President and CEO of MGMA. In her book: ‘Back to  balance:The art, science and business of medicine’ the author asserts:

We have lost our focus on strengthening the one thing that has always produced healthier patients, happier doctors, and better results: namely, strong relationships between patients and physicians, informed by smart science and enabled by good business.

In a separate blog post Larry Alton, business consultant addressing the business community says:

In 2017, you’ll find it difficult – if not impossible – to be successful without strategizing around customer communications. Customers have become conditioned to expect interaction and service. Provide both and you’ll be delighted with the results.

Most people will interact only with primary care when they need healthcare. The average consultation in primary care is less than 15 minutes. Therefore efficient communication is a priority. Larry Alton goes on to advise:

Communication is at the heart of engaging and delighting customers. The problem is that, even with all of the new advancements in communication technology, very few businesses are taking this all-important responsibility seriously. This results in poor relationships and a bad brand image.

His four key action points are:

  1. Hire empathetic employees
  2. Leverage the right communication mediums
  3. Use analogies to explain technical concepts
  4. Become a good listener

One area that seems to receive scant attention in medical practice is explaining technical concepts. And yet technical concepts are integral to medical practice:

  1. What pathology brought me here today?
  2. Why has my physiology responded in this way?
  3. What is the prognosis?
  4. Why do need this therapy?
  5. What are the risks?

Ours is a technologically proficient but emotionally deficient and inconsistent medical system that is best at treating acute, not chronic, problems: for every instance of expert treatment, skilled surgery, or innovative problem-solving, there are countless cases of substandard care, overlooked diagnoses, bureaucratic bungling, and even outright antagonism between doctor and patient. For a system that invokes “patient-centered care” as a mantra, modern medicine is startlingly inattentive—at times actively indifferent—to patients’ needs. Meghan O’Rourke

When explaining complex ideas there is a checklist:

  1. Does the patient want all the information?
  2. What are the implications of the prognosis?
  3. How can you explain with reference to something they are already know?
  4. What details can you leave out that would only serve to distract from an understanding?
  5. How can the patient assimilate this information actively?

Adapted from a post by Thorin Klosowski

Perhaps the neatest medium to communicate some aspects of a complex idea is the infographic. According to experts:

In the past 5 years, the term “infographic” has seen an impeccable rise in trend.In fact, the popularity of infographics is expected to see an increase of almost 5% by next year, meaning that anyone who isn’t yet riding the infographic bandwagon is bound to fall behind. The Daily Egg

Here are the data:

The Journal of Health Design has recently introduced the Infographic as a submission type. Communicating using this medium could reduce the time required to assimilate the information needed to make a decision.

Picture attribution

Designers will rescue the health sector

Much of what we do in healthcare is communicate ideas. That is far more common than ‘doing’. Executive control over decisions are the purview of the patient. It is a basic tenant of medicine that the patient has autonomy.

Often armed with little more than a stethoscope doctors must communicate to the patient that:

When communication about the evidence base is effective the patient, the practitioner and ultimately the economy benefit. How we communicate such ideas is where innovation has the brightest future. It gives us hope that we can improve outcomes in health without recourse to major policy change or curbing freedom of choice.

We communicate in words, pictures, video, audio and using models. Yet so much of how that is done in the doctor’s office hasn’t changed over the decades. ‘It’s just a virus’ doesn’t cut it any more.

We experience the power of effective communication everyday and in every other area of our lives. Look at your credit card statement this month- does it all make sense? What pressed your ‘purchase‘ button?

What if this extraordinary power deployed so effectively in commerce was unleashed in the clinic?

Picture by Dan Moyle

For best results engage the entire decision making apparatus

I’ve been sick for two days. I have a runny nose, headache, cough and I’m tired.

We agreed that it was very unpleasant having these symptoms when you are moving boxes around a warehouse all day. I examined him and found signs of an upper respiratory tract infection but nothing worse. Now comes the crucial part. If you are a doctor what do you say in the circumstances? You must have your speech ready because you will almost certainly consult someone like this every day, probably more than once a day. In an essay published in the BMJ Trisha Greenhalgh and colleagues wrote:

Evidence users include clinicians and patients of varying statistical literacy, many of whom have limited time or inclination for the small print. Different approaches such as brief, plain language summaries for the non-expert (as offered by NICE), visualisations, infographics, option grids, and other decision aids should be routinely offered and widely used. Yet currently, only a fraction of the available evidence is presented in usable form, and few clinicians are aware that such usable shared decision aids exist. BMJ 2014

What she appears to be hinting at is that words are not enough and may not efficiently convey what this man needs to make a decision for himself. He has already decided for whatever reason that he needs to see a doctor. He was probably able to ‘self-care’ by taking ‘over the counter’ symptomatic measures. Setting aside the notion that he might have presented to get a medical certificate to claim time off what else may be on his agenda? If we postulate that he might want prescribed medicines believing that they will hasten this recovery then there is the prospect of a disagreement with you as the ‘evidence’ suggests otherwise. He probably has a viral illness. But as David Spiegelhalter and colleagues wrote in Science:

Probabilities can be described fluidly with words, using language that appeals to people’s intuition and emotions. But the attractive ambiguity of language becomes a failing when we wish to convey precise information, because words such as “doubtful,” “probable,” and “likely” are inconsistently interpreted. Science 2011

What the person with the cold needs to know is that we cannot be sure what precise ‘bug’ has caused his symptoms. That the most likely cause is a virus but that his symptoms now do not predict the duration or severity of his illness. However most people get better within 10 days and he is probably suffering the most he will through this illness today. The worst symptoms are those he now describes. the cough may linger for a couple weeks.  Symptomatic treatment might help him feel better and that people who have been prescribed antibiotics do not get better any faster (that last bit is my team’s research which hasn’t yet seen the light of day in a peer-reviewed journal). However he may not factor all of this information into his thinking without pictures. We need to consider how he makes the decision to take your advice. Scientists have studied this and come up with some helpful advice recently. For a start the patient is unlikely to make a decision based on logic alone.

Behavioral economic studies involving limited numbers of choices have provided key insights into neural decision-making mechanisms. By contrast, animals’ foraging choices arise in the context of sequences of encounters with prey or food. On each encounter, the animal chooses whether to engage or, if the environment is sufficiently rich, to search elsewhere. Kolling et al

There are three treatment options; prescribe an antibiotic now, defer prescribing for a couple days or prescribe nothing. The latter is the appropriate course however a goal in this situation is to reach consensus with this person. To present the data to him in a way that engages his entire decision making apparatus. You are able to usher him out the door without anything only to find that he has lost faith in you. How he feels about the matter is critical:

A few years ago, neuroscientist Antonio Damasio made a groundbreaking discovery. He studied people with damage in the part of the brain where emotions are generated. He found that they seemed normal, except that they were not able to feel emotions. But they all had something peculiar in common: they couldn’t make decisions. The big think

The more challenging approach is to communicate respectfully, appropriately and effectively. Pictures can now assist as never before. Yet the habit of using pictures is neither taught nor practised consistently in clinics. Spiegelhalter again:

   The most suitable choice of visualization to illustrate uncertainty depends closely on the objectives of the presenter, the context of the communication, and the audience. Visschers et al. concluded that the “task at hand may determine which graph is most appropriate to present probability information” and it is “not possible to formulate recommendations about graph types and layouts.” Nonetheless, if we aim to encourage understanding rather than to just persuade, certain broad conclusions can be drawn, which hold regardless of the audience.

His team’s recommendations:

  • Use multiple formats, because no single representation suits all members of an audience.
    Illuminate graphics with words and numbers.
  • Design graphics to allow part-to-whole comparisons, and choose an appropriate scale, possibly with magnification for small probabilities.
  • To avoid framing bias, provide percentages or frequencies both with and without the outcome, using frequencies with a clearly defined denominator of constant size.
  • Helpful narrative labels are important. Compare magnitudes through tick marks, and clearly label comparators and differences.
  • Use narratives, images, and metaphors that are sufficiently vivid to gain and retain attention, but which do not arouse undue emotion. It is important to be aware of affective responses.
  • Assume low numeracy of a general public audience and adopt a less-is-more approach by reducing the need for inferences, making clear and explicit comparisons, and providing optional additional detail.
    Interactivity and animations provide opportunities for adapting graphics to user needs and capabilities.
  • Acknowledge the limitations of the information conveyed in its quality and relevance. The visualization may communicate only a restricted part of a whole picture.
  • Avoid chart junk, such as three-dimensional bar charts, and obvious manipulation through misleading use of area to represent magnitude.
  • Most important, assess the needs of the audience, experiment, and test and iterate toward a final design.

The last offers a call to arms for innovators.

Picture by Alan