Category Archives: Generic

Shared Decision Making

[NICE guidance 2021] See also participatory medicine and family centred care.

First bullet point is that this should be embedded at organisational level! Includes:

  • provide access to patient decision aids (PDAs) or information about risks and benefits
  • review how “information systems” might help record discussions and decisions, for example through patient held record
  • prompt patients (through media, posters, letters) to ask questions about options, and “making the decision that’s right for me

Staff training:

  • evidence based model eg three-talk model (introduce choice, describe options, help explore preferences and make decision)
  • communication skills – avoiding jargon, explaining technical terms
  • communicating with families and others the patient would like involved

Note that NHS England has “accessible information standards”.

In practice:

  • Agree an agenda
  • Ensure the person understands they can take part as fully as they want in making choices about their treatment or care
  • When it comes to tests or treatments, explain what the health care aim is of each option, and discuss how that might align with patients “aims, priorities and wider goals”
  • chunk and check information
  • check understanding eg teach back
  • Give information away at time of discussion or very soon after, including contact details
  • Write letters to the patient rather than to their doctor, in line with Academy of Medical Royal Colleges’ guidance on writing outpatient clinic letters to patients (and to patient, unless they don’t want a copy).

Communicating risk:

  • Make clear how information applies to them personally, and how much uncertainty applies
  • Use mixture of numbers, pictograms and “icon arrays” (repeated icons, with different colours, to see proportions), to allow people to see both positive AND negative framing
  • Be aware that different people interpret terms such as ‘risk’, ‘rare’, ‘unusual’ and ‘common’ in different ways
  • Use absolute risk rather than relative risk. For example, the risk of an event increases from 1 in 1,000 to 2 in 1,000, rather than the risk of the event doubles.
  • Use 10 in 100, rather than 10%
  • Use the same denominator
  • State both positive and negative framing

Participatory medicine

Patient led campaign for better involvement of patients in their own care.

Manifesto has 5 principles:

  • Share and listen – acknowledge patients are experts in their own lives and bodies, use plain language.
  • Respect one another
  • Share information responsibly – help patients access the information they need, and respect confidentiality
  • Promote curiosity – be clear even when it is difficult to explain, encourage patients to do their own research and get involved in patient communities
  • Be a teambuilder – treat patients as collaborators, respect their goals, values and preferences

These are shared responsibilities, the patient has their own duty to be honest, ask questions, advocate themselves.

Institute of Medicine describes a continuously learning system (in respect of healthcare in the US), the second feature of which is Patient-clinician partnerships. This is explained as “engaged, empowered patients – a health care system anchored on patient needs and perspectives, and promoting the inclusion of patients, families and other care givers as vital members of the team“.

Unclear this happens on any significant level, especially when it comes to communication outside the hospital or clinic room. Studies have found that when patient portals or messaging systems are used, patients often respond with further questions or comments, which suggests unmet need and desire to engage further. Other studies have found that only a tiny minority of messages in such systems are initiated by the health care team, which suggests a reactive rather than active contribution to the partnership.

History of Medical Failures

Where to start!? Leaches, blood letting, pretty much everything doctors did in the pre-modern period…

Thalidomide and birth defects, of course. But unforeseen.

X-rays for pregnancy monitoring. Took years before people paid attention to the alarms. X-rays were also used for tinea capitis – not just brain tumours, strokes and ischaemic heart disease about 30% higher too.

Ribavirin (via SPAG machines) for RSV. Not harmful, just useless and expensive.

Iron supplements for preterm babies – increased sepsis.

Expert patients

Idea came from Prof Kate Lorig, rheumatologist in US. Trained lay educators had better outcomes than conventional clinic appointments. In 2001, became an NHS programme, aimed at cutting costs of chronic disease.

Technology has aided this massively – see “E-patients“. But of course variations in access to technology and tech literacy.

Patient centred networks not well understood. Can have links to health professionals, but can also be tied to industry/commercial interests, may even be driven by industry.  Online resources scored higher with e-patients for convenience, emotional support, empathy, death and dying, in depth medical information, practical help.  Specialist physicians rated highest for diagnosis, technical knowledge (just), managing condition after diagnosis.  So online resources score highest where medics poorest and vice versa.  So combination of both ideal!  Also, medics come and go.  Some patient groups have published their own research eg GIST group.

But behaviour change, specifically when talking about self-efficacy, is very individual and psychology focussed. Less exploration of social influences, other than focus on peer modelling.

Foucault, of course, was fascinated by how people can become obedient, self governing, and how this is produced by the efforts of “pastoral power”, in a similar way to the Christian church and the process of confession.

Trisha Greenhalgh would say that although collaboration between patient and doctor is important, it’s still just one aspect of a whole system that includes community, material conditions, law/policy, social deprivation, cultural norms etc.

Brutalist medicine

“Architecture of medicine” a better metaphor than “art of medicine”, as it has a clear purpose? 

So Brutalist medicine: where so intentionally functional that it erects its own barriers. Eg protocols, scoring systems, electronic records that become monuments to themselves. But you can perhaps defend Brutalism’s desire to avoid unnecessary adornments.

[Benjamin Mazer, Yale-New Haven school of medicine]

Clinical teaching techniques

Set expectations – that most learning happens during daily patient care as part of the team.

Modelling – think aloud, to externalize reasoning (in short spells!)

1-2 minutes direct observation.  Feedback perhaps after a number of episodes – one thing done well, one thing that could be done differently?

Send student ahead (“scouting“).

Self- explanation – without any instructions, student finds own explanations for results, obs, management plan etc.

SNAPPS – summarize case, narrow differential, analyse differential, probe [ask questions] where uncertain, plan, select an issue related to case for self directed learning.  1-2 mins only.

Tell me story backwards – Diagnosis, then supporting evidence, then why other diagnoses excluded.  Only then plan.

Contrastive example – ask student to give alternative diagnosis and balance probabilities.

Post it Pearls – record thoughts (not just pearls!) during clinic/ward round, review at end.

Diagnostic challenge – one person/team defends working diagnosis. Other asks about worse case scenario, or alternative diagnosis, investigations done or not done, and checks with patient themselves!

[Operation Colleague, from University of Glasgow; HPE Bytes]

GIRFEC

Getting it right for every child. A framework for dealing with children and young people, looking at a range of values (SHANARRI).

Children and Young People (Scotland) Act 2014 made provision for Named Person and Child’s plan, but after review in 2019, amid privacy concerns (brought by Christian Institute, among others), government decided not to pursue legislation. Supreme court found that “duty to share information”, although well intentioned, was potentially at odds with article 8 of European convention on Human rights (“Privacy and family life”).

[https://www.gov.scot/publications/getting-right-child-practice-development-panel-report/]

Remote consultations – use of images

Clinical images are part of the medical record. Especially when they are being used to make clinical judgments, they should be retained, which means discussing transfer, storage and use of images.

Transfer – not subject to information governance and data protection rules until received! Whatsapp automatically uses end to end encryption.

Storage – needs to be deleted from your phone/device. NB Whatsapp has option to automatically save to phone. Arrange storage with NHS approved service, or else ask family to retain.

Use – needs specific consent to reproduce in any form, for specified purpose.

Document verbal consent.

If patients are unsure of sharing images, you could try sending illustrative images of the suspected condition.

Remote consultations

Schedule time, rather than fit in between jobs.

Confidentiality: where you are, where they are! “Are you somewhere private?”

Consent before you proceed. “Are you happy for us to talk just now?” “Can you hear me clearly?”

Contemporaneous notes.  Explain why there may be typing noises during conversation.

Beware if not your usual patient, and long term medication/condition.  Consult with GP or other appropriate professionals.

Prob not appropriate where Safeguarding issues or doubt about mental capacity of adults.

“You may need to justify a decision to consult remotely” – not for your convenience!!!

If speaking with a child, use speaker so parents can hear.

Since you can’t see cues and can’t nod in agreement, good to check understanding and summarise what has been said to you.

Say when you will phone back if you need to discuss with someone else.

Easy to become over focussed on one particular issue and forget to assess more fully.

If becomes emotional, respond by showing you have noticed “It sounds as though you are worried/angry/frustrated about…”.  Apologise if becomes hostile.  Focus on what you can do rather than what you can’t do.  Avoid pre-empting what someone is going to say.

If parents not reassured, or your assessment of the seriousness of the condition differs from theirs, err on the side of caution and arrange a face to face consultation.

For long term conditions, it may be helpful for family to have a list of concerns before hand.

When ordering tests, discuss how these will be fed back – consider whether likely to need face to face follow up to discuss results and treatment options.

Wait until the other party has hung up.

See also Remote consultations – use of images.

Audit

Process of collecting data against a set of standards, in an attempt to improve compliance with those standards. But often ineffective – especially when no changes made (“closing audit loop”) to improve performance. And slow – by the time you’ve collected the data and summarized it, you’ve wasted time that could be been used to improve things you’ve already seen going wrong.

Often just turns into criticism, with intervention being no more than “perform better”. And then just induces resistance.

Cochrane review of audits in general found median 4.3% improvement with compliance, which isn’t much, but potentially more with incremental gains and repeated audit. And potentially scalable. And about a quarter achieve nothing.

Audit chain only as strong as weakest link – awareness of standards, reliability of processes, feedback.  All aspects of programmed should be designed with a focus on desired change in behaviour, and barriers should be anticipated.

Checklist for doing audit well –

  • Can you recommend actions consistent with established goals and priorities
  • Actions that are under audience’s control?
  • Actions that are specific
  • Can you provide multiple data points as feedback ASAP – and as often as frequency allows
  • Individual as well as general feedback if possible
  • Can you provide comparators that reinforce desired behaviour change
  • Format of feedback – link visuals with summary message, multiple methods, minimize distractions.
  • Actionable plan along with feedback
  • Address barriers
  • Short, actionable message with optional detail
  • Realistic goals.
  • Address credibility. 
  • Anticipate defensive reactions
  • Construct feedback through social interaction

Feedback to clinicians, who all think they’re great, requires careful thought.  Trying to improve already high performance may be a waste of effort, there is a ceiling for most things where organisation close to max capacity.

Patients and the public often surprised by the extent of variation.  They express frustration at difficulties in routinely measuring less technical aspects of care, such as consultation skills and patient centredness.  Patients are an untapped force for change which audit could learn to harness.

[ Revitalising audit, BMJ 2020;368:m213]