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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

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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:

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The future arriving at an unprecedented speed

  •   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.

Here is my perspective on the challenge:

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It’s not the infrastructure it’s you that makes the difference.

CONTEXT:
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.
OBJECTIVES:
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.
METHODS:
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.
RESULTS:
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.
CONCLUSIONS:
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.

Mendick et al

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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.

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It’s not the gizmo it’s the operator who matters

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Small change, big impact

More on this from the Journal of Health Design.

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The most valuable lesson learned on my first day as a doctor

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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.

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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.

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