The Devil is in the detail

Recently I have had the unfortunate experience of having to take a member of my family to hospital – have them admitted, and stay there for about a week.

Luckily the system worked brilliantly at the front door and the treatment required was started promptly and appropriately, quite possibly preventing serious harm.

What followed after was a a mixed bag.  Some staff were excellent – going out of their way to explain what was going on, how things were progressing from their point of view, and allowing me to present my own ideas (along with those of friends with a specialist interest in the field) as to how things should be managed.  Others were less impressive – but probably for understandable reasons.  It was of interest to note that the more senior the doctors became – the harder it seemed for them to meet us at our level and have an equal conversation – resulting in some dissonance (Eric Berne has some answers for why this might have happened)

Doctors are a terrible bunch to have as patients – especially doctors with friends who can give advice with partial information, and thereby stick a spanner in the works for those in the team actually responsible for their care.

On reflection though – the difficulties did not come as a result of gross deficiencies in care, but in the details – single words here and there which made all the difference.  As you can imagine, parents of sick children pay attention to what doctors say.  If they have any kind of inkling as to what the doctors are saying implies then their hearing will be all that more acute.

Some of the disappointments during our stay came as a result of minor details – and I am sure that it was because we, as parents of the patient, were paying more attention to each and every word that was being said than perhaps the doctors were.

Other problems came later when we discovered that some things which had been told to us were simply untrue or inaccurate. This was especially hurtful – again, they did not amount to any negligence or deficiency in care – but they did waste time, effort and tears.

Having transferred to a different centre (for geographical practicality more than anything else) we were met by a team which seemed to work that little bit better.  Was this because hierarchies were obviously flatter – and communication between the senior staff and junior workers was more free? or simply that the confusion which exists at handover periods in the acute phase of an admission wasn’t present?

However, the details which made the difference continued – one team member very deftly avoided explaining the brutal truth of a possible course of treatment (one that was not necessary in the end) – and we are especially grateful for not having to confront that possiblility which ultimately never came to pass.

Well, whatever the reasons – we will continue to have mixed feelings about the first hospital, and have a better impression of the second – but for my own practice, I have now some experience on which to draw when dealing with my own patients – be they medics, nurses, plumbers or forestry workers (anyone really.)

And the lesson I have taken is that truly effective communication is a huge factor in the experience any patient has when receiving care – particularly as an inpatient.

And that communication must be consistent, accurate, and honest.

If not, you will lose the trust your patients have in you, and that can really damage the teamwork that is required between doctor and patient to tackle the mutual challenge of dealing with an illness and treating it effectively.

It’s how you tell ’em

I recently heard two stories which made me think again about communication skills.

In each case, the information delivered to the patient (in both cases friends of mine) was entirely correct.  The problem was not in the decision making, the outcome, the skill, accuracy or dedication of the professional discussing their case, but in the way it was discussed.

In one, a friend who had been seeing a specialist for really very regular follow up saw a new doctor.  The new doctor had read the notes, seen the progress, and – it felt to my friend – made a decision on how the consultation was going to go, and ended up discharging him.  This was all despite having never met the patient, not heard the background, having no idea of the context of the illness – but the numbers looked good, the progress was clear and therefore the decision was an easy one.

The second was a friend who, on remarking how lucky they had been was told in no incertain terms that acutally they weren’t lucky that the illness had not had such severe effects on them, but really that they had been lucky this particular doctor had been around to help them – as it was really their intervention which turned a dire situation into one which has become far more stable and manageable.  Again, this may well be true, but the experience left the friend feeling somewhat bruised by the encounter – especially as all of the previous consultations had been painted in a positive light, and that the disease was always manageable.

So what am I to learn from these?

Well, firstly that context matters – whenever you are going to deliver information to someone – especially when that someone is vulnerable, then tact is still required to determine what level of knowledge is appropriate, and how explicit it is possible to be without overloading someone.  This may sound paternalistic, but part of communicating a message is making it understandable.  All at once is fine for some people, but with many, realisation and recognition of a serious illness or problem is a stepwise process.

The other thing is that communication skills matter.  Paying attention to the participants in a consultation – appreciating where they are coming from, and what experiences they have been having are hugely important.  As we move more and more to efficient models of care, we have to ensure that we, as doctors, and other heatlhcare professionals do not allow ourselves to be caught up entirely in the “production line” and that we retain the important one-on-one relationships that are so important in medicine.

Both of my friends were really quite happy with their care – and the decisions about them and the information they received were absolutely correct.  The problem lay in how they were told – without real care or compassion.

Your decision might be the correct one, the outcome may have been perfect, but patients are humans, not statistics – and humans have feelings – we sometimes need to remember to tread lightly, no matter how bad a day we are having.

 

Seek first to understand, not be understood.

An argument is an emergency of self definition

In my day to day life I have the pleasure to meet a large number of people from all walks of life, and play a part in helping them through sometimes very difficult times in their lives.  This is the privilege and responsibility of being a doctor.  Usually people are very willing to enter into discussions about how they are feeling, what their symptoms are, how treatment has been going, and then listen when I go on to explain what I think is going on, and make a plan for further investigations or treatment.

More recently I have had some conversations with people that did not follow the usual, fairly polite, and respectful pattern.  In one case, the patient did not appear to want to enter into any form of discussion at all about what symptoms or problems may have brought him to the clinic.

Thinking back to the consultation, it was clear that the usual power dynamic had changed significantly – and, although I was aware of it at the time, it seemed that I should try to get the consultation back to the usual footing – as that is how we operate in medicine.  This resulted in a fairly frank exchange, and both parties undoubtedly did not perform at their best.  However, the plan we arrived at was appropriate for the condition being considered and although the consultation was not terribly satisfactory – it ended up being effective.

Now, why did this small-scale conflict arise?  There were undoubtedly faults in the system that led to communication errors in written information.  But when I really look back at what was going on at that moment – I can see a couple of things.

#1 The patient was really upset at the medical profession as a whole owing to limitations placed on him by medical examinations, which he did not believe were justified.  He had most probably lost out on a significant amount of income, and was therefore not pre-disposed to cooperate with the medical establishment.

#2 I was unconsciously unhappy that the power dynamic had shifted away from me in the consultation – and I therefore tried to re-assert my authority when questioned again and again about each detail of my plan.

So, what will I learn from this experience?

First, that a saying I learned recently and have tried to practice will require more work – namely – “Seek first to understand, rather than to be understood”  By examining more closely the reasons why this patient was unhappy, I could actually identify the likely reasons for the conflict, and in accepting that these were of great importance for the patient, include them in my appraisal of the situation, and allow the patient time and space to express this frustration, and then move on to the other needs the patient had from that consultation

Secondly, to recall that ‘arguments are emergencies of self-definition’ and act accordingly.  I read this phrase recently in a short story (Aftermath – Rachel Cusk), and was struck by it as representing a simple truth.  In this consultation, the ‘argument’ arose because the patient wished to express their feelings or displeasure at previous experiences, irrespective of my lack of role in them, and I wished to assert my position as that of the doctor, and inherently therefore deserving of respect and deference in the consultation.

In the future I need to recognise that there are times when what a patient needs from a consultation may not be entirely relevant to what I think they are there for.  Trying to force the issue down another road is not likely to leave either party satisfied. It is far better to be alert to this possibility and deal with what is most important for the patient – and place my needs slightly lower down the scale until the patient will be in a better frame of mind to work together on the issue I am seeing them for.  Ultimately I would like to get to the position where every one of my clinic appointments is run along the principles of shared decision making – but that is a work in progress.

Language – a double edged sword

Doctors are like a number of other professions in that they have a specialized language which helps them to communicate all sorts of complex information to each other, and helps them to be precise in what they are describing to one another.

The process of learning this language can be confusing.

Recently some medical students were asking what was meant by the term ‘pulmonary congestion’ and how this was different to ‘alveolar oedema’ or ‘pulmonary oedema’ or ‘interstitiial oedema’ or   I struggled to provide a decent explanation for each of the terms other than that they were basically all the same thing.

We then discussed how you might go on to explain such a process to a patient – out came a reliable phrase: ‘fluid on the lungs.’  The conversation continued, and we started to discuss how you might explain a pleural effusion to a patient…  And again – “fluid on the lungs”

So there, we go – doctors have managed to reduce two incredibly different and distinct processes which require entirely different treatment modalities, and hold very different implications to a single ‘simple’ phrase to communicate these things to patients.

The common term for describing technical language is ‘jargon’ – defined as language or terms which are  ‘not likely to be easily understood by persons outside the profession

If we look at how this affects doctors and patients – we can see from a few studies, and from experience that using jargon can reduce patient understanding in consultations – this review highlights some of the points about patient-doctor communication which would be sensible to keep in mind when talking to patients and this consensus statement offers a framework for key elements of communication in medical encounters.

There is less guidance for what phrases we should use to describe pathological processes to patients – and so a vocabulary has arisen which is in common usage but seems to be oversimplified and hence confusing to patients and students alike.

So what is the solution?  Well jargon – as well as being a tool of exclusion to keep students on their toes, can also be useful.  It is sometimes helpful to be able to discuss elements of a case with colleagues using a ‘code’ instead of graphic detail – and this is done all the time in front of patients, and in corridors.  Jargon, therefore can be useful – if it is justified is more contentious.

However, when explaining things to patients, I really think that we don’t have to oversimplify things – using diagrams, simple language and examples from other areas of everyday experience it is possible to communicate quite complex processes to patients.  If we do not take the time, and instead use phrases which are so simple as to be opaque, we are at risk of misleading patients, causing confusion and therefore reducing their chances of understanding their disease.

Higher rates of health literacy and effective education have been associated with better outcomes in some areas but in others, may have contributed to non-adherence following discharge from hospital (possibly a good thing – health outcomes weren’t measures in this study- but prescription inaccuracy was quite high!)

Ultimately, jargon is here to stay.  For those interested in the NHS, and respiratory medicine in general there is a fantastic glossary published and kept up to date by IMPRESS.

Without being aware of how we are using language at work – either through excessive complexity, or inaccurate simplification – we are at risk of excluding patients, colleagues and students from the conversation, at the very points where they should be integral to it.

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.