In this week's consultation we deal with the highly informed and opinionated patient.
Access to information has changed fundamentally, and this is in turn changing communication between healthcare professionals and their patients.
The man or woman in the street, on the bus or in the outpatients department, now has a key to unlock almost unlimited medical knowledge, and if the circumstances of their lives dictate it they will seek out this information.
This changes the expectations you might have about your role as a doctor. Previous generations doled out knowledge to patients in carefully titrated doses but withheld enough to retain power of influence.
Doctors can no longer do that.
In 2010, as soon as a major health event occurs to a human being or one of their family, someone in that circle will seek out information, usually with a few clicks of a mouse.
Within minutes, they will have more information on the subject than you can possibly carry in your head. This is a huge change for doctors. Since recorded history, and from anthropological research even before that, doctors, shamans and priests have controlled medical knowledge. Now the genie is out of the bottle and patients demand a different form of communication than that which medics have been used to for thousands of years.
Research from the UK shows that patients with AF who were likely to benefit from anticoagulant therapy declined warfarin therapy when presented with the data about the absolute risks and benefits.
There is considerable research and development going on into health decision aids (HDAs), which show patients a number of reasonable strategies and possible outcomes.
Curiously, several observational studies have shown an apparent under-use of antithrombotic drugs in patients with AF, despite evidence of efficacy.
There is also considerable variability between physicians and patients in their weighing up of the potential outcomes associated with AF and its treatment.
For anticoagulation treatment to be acceptable to patients, they required less reduction in the risk of stroke and were more tolerant of an increase in risk of bleeding than physicians.
Physicians varied considerably in how much risk of bleeding they thought was acceptable for a given reduction in risk of stroke associated with antithrombotic drugs.
In our video consultation, the doctor does not attempt to use an HDA but does give the patient the consultant's letter and a standard warfarin leaflet.
In the view of most GPs, this patient would be considered difficult because he consistently challenges the 'expert' knowledge of the doctor - and he himself is well aware of this fact.
He is, however, not wrong, stupid or stubborn. He just wants what is best for himself and his family. He also wants an explanation and treatment plan that fits with his educated belief system and does not wish to be fobbed off with 'doctor knows best' strategies.
|The Key Tasks|
1. Understanding the reason(s) why the patient has attended.
2. Understanding the nature of the patient's problem.
3. Explaining or preferably sharing an understanding.
4. Management, the sharing of decision making and responsibility.
5. Being effective. Making best use of the consultation time.
In the jargon, he is clearly an 'internal controller' and wants a Socratic dialogue with his health professional on the level of equals. Doctors pay lip service to wanting patients to be involved in decision making but the common reality is we like patients to be a little bit subservient and take what we say on trust.
The next decade is going to be more difficult because of the rise of the informed and opinionated patient. Theresfore, doctors will have to consult more personally, and learn how to negotiate while always focusing on the individual not the generality.
This will not be easy, the systems are against us. We live in a time of organised discontinuity, and our salaries are based on epidemiology not individual health. We can make money without treating the individual, but what about job satisfaction?
The practise of medicine has always revolved around consulting skills, bedside manner, and ability to inspire trust.
Despite the pressures of modern medical delivery this still holds true, and perhaps good consulting is now needed even more than before, as the eternal doctor-patient relationship approaches an equality not seen before.
- Dr Tate was convenor of the panel of RCGP examiners from 2002 to 2006. He is the author of The Doctor's Communication Handbook, now in its sixth edition, from Radcliffe Publishing.
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References and further reading
- Lane D, Lip GYH. Anti-thrombotic therapy for atrial fibrillation and patients' preferences for treatment. Age and Ageing 2005; 34: 1-3.
- Protheroe J et al. The impact of patients' preferences on the treatment of atrial fibrillation: observational study of patient based decision analysis. BMJ 2000; 320: 1380-1384 (20 May).
- Devereaux PJ et al. Differences between perspectives of physicians and patients on anticoagulation in patients with atrial fibrillation: observational study. BMJ 2001; 323:1218 (24 November).
- Kravitz RL, Melnikow J. Engaging patients in medical decision making. The end is worthwhile, but the means need to be more practical. Editorial BMJ 2001; 323:584-5
- Smith R. The discomfort of patient power. Medical authorities will have to learn to live with ‘irrational' decisions by the public. Editorial BMJ 2002; 324: 497-8
- Matthys J, Elwyn G, Van Nuland M et al. Patient's ideas, concerns, and expectations (ICE) in general practice: impact on prescribing. Br J Gen Pract 2009 Jan; 59 (558): 29-36.
- Lafuente-Lafuente C, Mahé I, Extramiana F. Management of atrial fibrillation. BMJ 2009; 339: b5216.
- Ahluwalia S, Murray E, Stevenson F et al. ‘A heartbeat moment': qualitative study of GP views of patients bringing health information from the internet to a consultation. Br J Gen Pract 2010 Feb; 60 (571): 88-94.