Patient choice – where does that leave doctors?

Doctors got a lot of bad press in the past for being paternalistic, not involving patients in decisions about their treatment – as exemplified by Sir Lancelot Spratt in this clip (see 1:30)

The King’s Fund recently published a report on shared decision making, and highlight some of the challenges, and benefits of a ‘shared decision making’ approach to the medical consultation. All of the recommendations are pertinent to most consultations and the general advice is excellent.

However, a recent paper shows that patients, when it comes to some decisions, would prefer their doctor to take a leading role.

So where does that leave us doctors as we consult with patients with different health beliefs, different attitudes to their entitlements and different agendas when it comes to their own healthcare? Trish Greenhalgh has written an excellent paper looking at this

I would like to say it puts us in the driving seat – with access to the data, both official and anecdotal. With that comes responsibility. As we move to seeing more and more ‘provider organisations’ entering the health economy, patient choice is likely to expand – and with it, the number of decisions to be made regarding treatment and investigations.

Shared decision making relies on the fact that patients are informed enough to be able to make a choice about where or when to be investigated for a possible condition. This is a ‘good thing’. I love the idea that patients in the future will be able to discuss with their GP about which hospital offers the best service for a particular condition, how far away they are, what the waiting time is like, what the outcomes have been for previous patients with similar problems… BUT

And it is a big BUT – this relies on accurate, up to date and relevant information. Open data projects which are being geared up and are providing health-related data to the public domain like the London Datastore are a step in the right direction, and the recent interest in health apps as publicised yesterday by the Department of Health here will go some way to democratising the information about health services, and empowering patients.

There is however, some more basic, down-to-earth common sense which is required in all of this – and a couple of patients I have seen recently illustrate this perfectly.

One was a lady with a history of cough – which resolved after a period of a few weeks. She had attended one hospital, had an x-ray and the report indicated that TB could not be ruled out. Choose and book being what it is, she was offered a choice – and chose to come to my hospital for further specialist attention.

The second was similar in that three chest x-rays had been taken at one hospital, and as the appointments on choose and book indicated a quicker consultation at my hospital, the patient chose it rather than the one where the x-rays had been performed.

In both cases the patients had gone through what must have been some sort of decision making process with their referring doctor. Now, they may have had an excellent discussion about the relative merits of each of the institutions available to them, but something fundamental was missing – the fact that the NHS is not, has never been , and if competition between providers increases, probably never will be an organisation which is excellent at sharing information at the drop of a hat, or transferring things like x-ray films and images between institutions.

However, that is not the image of the NHS that patients have, and their expectation – in the world of instant messaging, flickr and facebook – is that images and information should be flowing freely like water.

So – yes, let’s get more shared decision making into the consultation room, but let’s not forget that:

1. Doctors have a duty to advocate for their patients, and we should take into account the additional guidance some patients need in complex situations.

2. There are still some very mundane limits to the efficiency of the NHS and the strife that this causes patients when they realise that their questions cannot be answered, and never could be by the doctor they ultimately consult with.

Patient ‘choice’ as it becomes more and more fashionable will mean many things to many people – but patients should not suffer as a result of doctors being poor advocates, and not highlighting all of the important information – even if it is simply the logistics.


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