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.
If you have had to consult a healthcare practitioner there will almost certainly have been an occasion when you were advised to have a test or X-ray. But to what extent could you have been misled by the results of that test? Well it depends. The issue may seem complex but the science need not be inaccessible.
Purpose: To conduct a video vignette survey of medical students and doctors investigating test ordering for patients presenting with self-limiting or minor illness.
Methods: Participants were shown six video vignettes of common self-limiting illnesses and invited to devise investigation and management plans for the patients’ current presentation. The number of tests ordered was compared with those recommended by an expert panel. A Theory of Planned Behaviour Questionnaire explored participants’ beliefs and attitudes about ordering tests in the context of self-limiting illness.
Results: Participants (n=61) were recruited from across Australia. All participants ordered at least one test that was not recommended by the experts in most cases. Presentations that focused mainly on symptoms (eg, in cases with bowel habit disturbance and fatigue) resulted in more tests being ordered. A test not recommended by experts was ordered on 54.9% of occasions. With regard to attitudes to test ordering, junior doctors were strongly influenced by social norms. The number of questionable tests ordered in this survey of 366 consultations has a projected cost of $17 000.
Conclusions: This study suggests that there is some evidence of questionable test ordering by these participants with significant implications for costs to the health system. Further research is needed to explore the extent and reasons for test ordering by junior doctors across a range of clinical settings. D’Souza et al
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
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
You now hear it all the time ‘in the future doctors will consult on-line’. The days of the office visit are numbered. However before then there is a generation of doctors who must find a way to fit into this new world. A little over two years ago the Royal College of General Practitioners released the following summary of ‘the consultation’:
As a general practitioner you must show a commitment to patient-centred medicine, displaying a non-judgmental attitude, promoting equality and valuing diversity
Clear, sensitive and effective communication with your patient and their advocates is essential for a successful consultation
The epidemiology of new illness presenting in general practice requires a normality-orientated approach, reducing medicalisation and promoting self-care
Negotiating management plans with the patient involves balancing the patient’s values and preferences with the best available evidence and relevant ethical and legal principles
As a general practitioner you must manage complexity, uncertainty and continuity of care within the time-restricted setting of a consultation
The increasing availability of digital technology brings opportunities for easier sharing of information and different formats of consulting, as well as raising concerns around information security. RCGP
The summary suggests that the consultation will survive. However the rate of change in every other service is such that the notion of ‘negotiating’ seem quaint as more choices are made directly available to the consumer. Healthcare providers need to be part of the solution as was suggested in this research:
Communications technologies are variably utilised in healthcare. Policymakers globally have espoused the potential benefits of alternatives to face-to-face consultations, but research is in its infancy. The aim of this essay is to provide thinking tools for policymakers, practitioners and researchers who are involved in planning, implementing and evaluating alternative forms of consultation in primary care.
We draw on preparations for a focussed ethnographic study being conducted in eight general practice settings in the UK, knowledge of the literature, qualitative social science and Cochrane reviews. In this essay we consider different types of patients, and also reflect on how the work, practice and professional identities of different members of staff in primary care might be affected.
Elements of practice are inevitably lost when consultations are no longer face-to-face, and we know little about the impact on core aspects of the primary care relationship. Resistance to change is normal and concerns about the introduction of alternative methods of consultation are often expressed using proxy reasons; for example, concerns about patient safety. Any planning or research in the field of new technologies should be attuned to the potential for unintended consequences.
Implementation of alternatives to the face-to-face consultation is more likely to succeed if approached as co-designed initiatives that start with the least controversial and most promising changes for the practice. Researchers and evaluators should explore actual experiences of the different consultation types amongst patients and the primary care team rather than hypothetical perspectives.
Communication education has become integral to pre- and post-qualification clinical curricula, but it is not informed by research into how practitioners think that good communication arises.
This study was conducted to explore how surgeons conceptualise their communication with patients with breast cancer in order to inform the design and delivery of communication curricula.
We carried out 19 interviews with eight breast surgeons. Each interview centred on a specific consultation with a different patient. We analysed the transcripts of the surgeons’ interviews qualitatively using a constant comparative approach.
All of the surgeons described communication as central to their role. Communication could be learned to some extent, not from formal training, but by selectively incorporating practices they observed in other practitioners and by being mindful in consultations. Surgeons explained that their own values and character shaped how they communicated and what they wanted to achieve, and constrained what could be learned.
These surgeons’ understanding of communication is consistent with recent suggestions that communication education: (i) should place practitioners’ goals at its centre, and (ii) might be enhanced by approaches that support ‘mindful’ practice. By contrast, surgeons’ understanding diverged markedly from the current emphasis on ‘communication skills’. Research that explores practitioners’ perspectives might help educators to design communication curricula that engage practitioners by seeking to enhance their own ways of learning about communication.
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
We do not gain weight steadily through the year. In fact, it is primarily from the end of November to mid-January that we find ourselves tempted and triggered to eat more than we need. With a seemingly endless round of invitations to partake in sugary treats most people succumb and add up to one kilo to their already growing girth.
The average BMI of males in their 40s in the West is 25.6 to 28.4. The numbers are similar for women. In other words, most are overweight. Researchers document that during this holiday season adults consistently gain weight during this period (0.4 to 0.9 kg).
Participants seeking to lose weight appeared to increase weight although this was not consistently significant and motivated self-monitoring people also appeared to increase weight. These results must be considered for registered dietitian nutritionists, other health providers, and policy makers to prevent weight gain in their patients and communities during this critical period.
Obesity is an epidemic with a rising tide of chronic and life-limiting illnesses in its wake. As healthcare professionals,
we need to be confident about raising the issue of overindulgence without putting a damper on the festivities.