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An immodest proposal for medical education

Right at the very beginning of their studies, medical students have strong ideas about what kind of doctor they want to be, even if they know very little about how to actually be a doctor. In one study medical students regarded empathy, motivation to be a doctor, good verbal communication, being ethically sound and honesty as the most important qualities. Medical education needs to be radically reformed if it is to support these ideals which are too easily lost.

Educationalist, Sir Ken Robinson interviewed on radio 4 last week, was asked whether he thought it necessary to master basic skills in literacy or numeracy before giving expression to language or mathematics. He responded,

“Well it’s wrong … it’s just not true. It is important that you learn these things as you go on , but this is a matter of pedagogy. I mean for example, we’re here in Liverpool, this was the birthplace of the Beatles. When they started out they knew about three chords but they had fantastic energy, compassion, enthusiasm for music. Well, nobody would deny that they became much more sophisticated musicians as they went on, but they were impelled to become more sophisticated by their passion for the music they were creating.”

He continues to say that great teachers give students a passion for their subject and their enthusiasm for learning follows from that. We need to give medical students a passion for the practice of medicine right from the first day they start medical school.

I’ll acknowledge here, that increasing numbers of medical schools have introduced patient-contact in the first year. But it needs to go much further.

The entire first year of medical school should be vocational.  Students should spend the whole year seeing how medicine is practised from the perspectives of different types of doctors, allied health professionals, managers, policy makers and most important of all, patients. They need to know what it’s like to live with a chronic disease and deal with doctors and the health and social care systems in which they will one-day work. They should learn about what it means to be a professional, about the privileges, responsibilities and stresses of their profession. They should learn from close observation and role models about the responsible use and irresponsible abuse of power. A grounding in narrative medicine and the medical humanities will be essential for them to develop the ability to critically balance such a wide range of perspectives.

They should learn about medicine’s historical, social and political roots, the role of advocacy and the importance of global health, public health and the social determinants of health.

To make sense of this they will need plenty of opportunities to meet with their peers and more experienced mentors to see how their experiences fit with their preconceptions and their ideals. This is how most medical education should happen, especially if we want our students to understand the complexity of clinical practice. These groups would be ideal fora for discussing the contested grounds of professional behaviour and medical ethics and learning about the value of narratives, the skills of peer supervision and the ability to reflect.

At the end of this year, they should be asked a question,

Which of you still wants to be a doctor?

If the experiences are sufficiently rich, both wide-ranging and deeply considered then there will be a minority who have discovered that medicine is not at all what they had expected (or it is as bad as they had feared, but had hoped it was not) and they will have the opportunity to change career before investing several more years of their life and money.

Those that remain will be much clearer than most medical students are at present, about what it means to be a professional, why medicine matters and what matters to patients.

And when they then start their basic medical sciences their ideals will be rooted in an ethically informed professional identity, a much clearer idea of their heritage and their future.

And, one would hope, their learning will be impelled by their passion.

Beyond first impressions

“Jennifer Jones?!”
“Jennifer… JONES!”
“Mrs JONES!”

Three times I called, increasingly loudly across our large, busy waiting room, each call louder and more impatient than the last. A few patients, especially those who were hard of hearing or didn’t speak English, stood up, looked hopefully or asked me to say the name again. I all-but-scowled at them. I was exhausted, my surgery was running 25 minutes late, I was the only partner in the building and almost every consultation was interrupted by a phone call from another doctor, nurse or receptionist.

Somebody who evidently wasn’t Jennifer Jones – because she was a lot younger than the 86 years I knew Mrs Jones to be – almost ran over to me.

“I’m really sorry Dr Tomlinson, she had to use the toilet, she’ll be out in just a minute”

The woman ran back and knocked on the toilet door, “quick mum, the Doctor’s calling you!”

I sighed, gritted my teeth and looked at my watch. I was holding open the door between the corridor outside the consulting rooms and the waiting room, as other patients walked passed and other GPs called their patients in.

“Fatima!” Dr Brown cheerfully called her next patient in by her first name. Fatima stood up, obviously in discomfort, but greeted her GP with reciprocal warmth, and they walked down the corridor side by side.

Several patients were watching all this from the waiting room. Jennifer Jones’ daughter was helping her mother shuffle over towards me and I was shuffling irritably on the spot. I spotted my next patient and apologized for the wait, gesturing to Mrs Jones.

The next day I was supervising a trainee GP working in our out of hours service, CHUHSE. She is a fully qualified doctor, with 3 years of hospital medicine behind her, but this was only her 4th out of hours GP session and she wanted to watch me manage a few calls from patients and then for me to watch her. Most of the out of hours work is answering patients’ calls by phone. A few days before, in preparation for our session, I had asked her to read an essay by GP/sage, John Launer called, The Three Second Consultation.

We imagined what it might be like if we taught medical students and doctors the importance of the first three seconds of any encounter with a patient. This would mean training them to be alert to every verbal and non-verbal cue that patients brought with them into the consulting room. It would mean making sure that our initial responses were calculated to put patients at their ease, gain their trust and set the scene for a productive consultation.

Before we stared I asked her if she had read it, she said she had but wasn’t sure of what to make of it – after all, it’s what she tries to do all the time. So for the next few consultations we agreed to concentrate on the first few seconds. We prepared by reading the records we had. We listened for how the phone was answered; hurriedly, anxiously, suspiciously, or more relaxed. What background noises were there? A screaming child, street sounds, a bus? We made sure that we gave callers our full names and titles, explaining as often as was necessary. Our calls began with #hellomynameis. We asked who it was we were speaking to with the same attention to detail. Very often we were speaking to a friend or family member rather than the patient and names were often difficult for us to understand, so we checked spelling. The trainee and I listened carefully to the tone of each other’s voices, for kindness, concern, confidence and reassurance and to the tone of the caller’s voices for fear and concern, comprehension and any other clues about how they were feeling. As we worked our way through consultations the effort required for such close attention became progressively less and it felt more natural.

After a couple of hours we had a short break and I had to share a confession. I told my trainee about how I had behaved in surgery the day before with Jennifer Jones, about the tone of my voice, her anxious daughter, the looks on the faces of the other patients in the waiting room, about the impression this must have given to the other patients, the stress and irritability that must have spread and affected the rest of the surgery.

What I discovered when I went back to work the following day, even though I had far too little sleep after the out of hours shift, was that I was so attuned to the first few seconds of every patient meeting, that every consultation seemed a little easier than usual. Our receptionists, who saw me stand in the doorway to the waiting room 19 times that morning and call every patient in with a smile and greet them with an introduction and a handshake, noticed the atmosphere in the waiting room lift.

 

What I learned was not just the importance of first impressions, but what can be learned from having someone watch me at work. Making the implicit – what you do unconsciously – explicit for the benefit of a witness, reveals things you knew but had forgotten or neglected, or let slip under the duress of workload and stress. I’ve been a patient often enough myself to appreciate just how often simple courtesy is neglected. As accomplished surgeon Atul Gawande notes, even the best sports-stars or doctors can benefit from coaching but we need to be prepared to perform under the watchful eyes of others and be open to critical feedback.

Feedback from our peers, who understand what it is like to try to be cheerful, patient and compassionate when we are stressed, running late and constantly criticised, is essential. My trainee was as quick to respond with kindness and forgiveness to my ‘confession’ as she was to appreciate the value of what we were achieving by paying such close attention to the first few seconds.

As doctors we need to be critically reflective teachers and to do this we must be able to reflect on our own practice, invite our peers, our students and our patients to appraise our practice, and engage with the literature that illuminates the things we may have forgotten.

80% of GP practices have one or more GPs suffering from Burnout

Originally posted on pracmanhealth:

Are you in despair for your future in General Practice – Final Report

In 2013, my practice advertised in the British Medical Journal, on two occasions, for a salaried GP with a view to partnership. This recruitment process resulted in only one credible candidate. At the time my surgery constructed an unconvincing narrative to explain our failure to recruit. During the year and early in 2014 we spoke with other surgeries in Oxfordshire and realised that we were not alone in being unable to recruit.

In April 2014 we ran a Survey Monkey questionnaire across GP practices in Oxfordshire. We received 167 replies in the space of a few days. This convinced us that there was a serious situation developing that could affect the future of General Practice. At the end of June 2014, at the request of a group of concerned GPs from North and North-East Oxfordshire the survey was…

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Smoking, oxygen and COPD

In this edition of Inside the Ethics Committee the question is, ‘should home oxygen therapy be allowed in patients with severe chronic obstructive pulmonary disease (COPD) who continue to smoke?’

I don’t have time for a ‘proper blog’ but here are some brief notes and links.

The reasons that oxygen might not be allowed are because in the presence of oxygen, things (like oxygen tubing, facial hair, clothing, etc.) are much more flammable and patients, including one of mine, have set fire to their heads resulting in serious burns and occasionally even death.

Oxygen therapy is used in patients who have Chronic Obstructive Pulmonary Disease (COPD), and is delivered through plastic tubes that go up the patients’ nostrils. Quite a lot comes out of the nostrils and effectively bathes the face, head and clothing. Patients have set fire to themselves when not smoking, for example lighting stoves, and one patient was killed when an e-cigarette exploded.

The tubes that the oxygen goes through are made of PVC which is quite flammable and releases highly flammable vinyl chloride gas when it burns.

Oxygen therapy is used in patients with COPD to reduce the risk of complications like pulmonary hypertension, heart failure (caused by the strain of pushing blood through the damaged lungs) and polycythaemia (thickened blood). In very severe COPD when the oxygen levels fall below about 92% patients feel confused or ‘foggy headed’ and the oxygen helps with this. Stopping smoking is a far more effective way of reducing these complications than oxygen therapy.

An assessment for oxygen therapy is often completed when a patient has been admitted to hospital with a deterioration of their COPD, for example with a chest infection. Unfortunately the assessment is not often repeated after the patient has been discharged. This is unfortunate because by then the patients’ condition has considerably improved and oxygen may no longer be necessary.

The symbolic value of oxygen.

Everybody knows that you need oxygen to live, and without it you die.

Taking oxygen away from patients is very difficult.

The perception (I’ve spoken to some of my patients about this) is that once you need oxygen, it’s pretty much the only thing that’s keeping you alive, and if anyone takes it away, pretty soon afterwards, you’ll die. Hearing these concerns, taking them seriously and working through them is difficult. I left the programme not entirely convinced that we had explored this issue enough.

Whole person care.

Anxiety, depression and feelings of shame and guilt are very common among patients with severe breathlessness, especially among smokers who quite frequently blame themselves for being a burden on their families and others. A smoker interviewed for the program who set fire to himself while using oxygen was too ashamed to go to hospital and waited until the next day when the pain was unbearable, before going. The more we punish and shame people the more isolated and self destructive the are likely to become. Our job is to help people who need it. Oxygen therapy provides relief from some of the anxiety, but sadly effective psychological support is often lacking and oxygen is a kind of substitute.

The bottom line.

I think that we should only prescribe oxygen therapy to smokers if certain conditions are met:

  • we have done everything we can to help them stop smoking
  • they are fully aware of the risks and awareness is not impeded by intoxication or other reasons, e.g. dementia
  • they have demonstrated the ability to smoke safely, i.e. stop the oxygen for 10 minutes and then going outside before smoking
  •  we have made every possible effort to help them with underlying anxiety, shame and depression (where it exists)
  • they have been given every opportunity to discuss their understanding about the risks and actual (and symbolic) benefits of oxygen therapy
  • We have done what we can to mitigate the risks, e.g. good ventilation, safer oxygen delivery systems
  • We have repeated the assessment to show that oxygen therapy is still effective and no safer alternatives exist

It seems very unlikely that in the case of the last patient discussed in the programme, that these conditions could be met and oxygen should not therefore be prescribed.

Links 

Use of oxygen therapy in COPD 

In New Calculus on Smoking, It’s Health Gained vs. Pleasure Lost. A little-known cost-benefit calculation that public health experts see as potentially poisonous is the happiness quotient. It assumes that the benefits from reducing smoking — fewer early deaths and diseases of the lungs and heart — have to be discounted by 70 percent to offset the loss in pleasure that smokers suffer when they give up their habit. NY Times August 6th 2014

Doctors, patients and shame – stigma, shame and blame experienced by patients with associated with lung cancer.

Some patients said that family or friends had not been in touch since they heard about the diagnosis. One patient with mesothelioma said that his daughter had not telephoned because she felt “dirtied” by contact with cancer.

Long-term oxygen therapy and quality of life in elderly patients hospitalised due to severe exacerbation of COPD. A 1 year follow-up study: In conclusion, the future need for LTOT cannot be judged after a few days treatment in hospital due to exacerbations with hypoxaemia in elderly patients with COPD. A standardised oxygen withdrawal test can be safely done. Health-related QOL is low in patients during the stay in hospital, but improves after returning home.

Home Oxygen Therapy and Cigarette Smoking: a Dangerous Practice: Patients are told not to smoke, but recent surveys show the percentage of home oxygen users still smoking to be between 14 and 51%. The use of a less combustible material for cannula tubing and a more efficient oxygen delivery system may reduce the incidence of such burns. Another suggestion would be labelling the oxygen cylinders with large stickers emphasizing the danger of smoking in the presence of oxygen.

Got a match? Home oxygen therapy in current smokers  Fortunately, at least 30% of patients meeting the criteria for domiciliary oxygen after 1 month of apparent stability no longer met the same criteria after an additional 3 months of observation

Smoking and Home Oxygen: Doubling the Danger There is no safe way to smoke when using home oxygen. Until patients quit, they can practice safer smoking. Should an individual need to smoke, it’s important to first turn off the tank, and wait 10 full minutes before going outside to smoke. This practice should decrease the amount of oxygen in the home and on the person. The best way for patients to protect themselves, their families, neighbors, and emergency responders is to quit smoking.

Home oxygen therapy. Adjunct or risk factor? 27 patients were admitted to a burns unit as a result of burns sustained while using oxygen therapy over 10 years, 25% were had terminal illnesses and ‘many’ were receiving hospice care. 24 were smoking, 2 were lighting pilot lights, 1 was lighting wife’s cigarette. 4 (15%) Died

Palliative care in chronic obstructive pulmonary disease: a review for clinicians.

The Wounded Healers

John barely noticed the rain that soaked through his expensive shoes and made his cigarette smoulder. Lisa’s pink fur slippers soaked up the rain like sponges but her feet were warm enough. Anna stood more comfortably between them in brown suede boots, as they leaned over the railings in front of the Accident and Emergency department gazing blankly through the rain. Ambulances rolled in almost silently, lights flashing, sirens off. It was raining less heavily than it had during the day, but it made the darkness feel closer. They smoked in silence. Across the car park, they could see the glows from near the gates, where those inhaling more pungent substances huddled together, occasionally sharing their smokes with the security guards.

The rain tapped on the windows as lights pulsed from machines that pipped quietly in the night, controlling the drip of fluids in and data out of Sally’s arms. She looked peaceful now, so different from when her ambulance rushed her in this morning. John had watched helplessly, banished to the side-lines as paediatricians and anaesthetists worked their way through their protocols. Watching was unbearable, and not only because it was his own child being stabbed repeatedly with needles, masked, bound and gagged, blooded and drugged, which is of course the brutal reality of what happens when emergency care meets serious illness. Worse was watching the blundered cannulations, the repeated transgressions of aseptic technique, the delays in administering drugs, the failure to find the right piece of equipment, the delay in summoning the consultant, the arguments about whether to transfer her to another hospital. This was unbearable.

On one of the wards one of the nurses had left her evening medication round to help a distressed and demented patient, “Somebody’s stolen my slippers!” the old lady wailed and other patients called out to tell her to be quiet. The drug trolley was left open and unsupervised as together they looked under her bed. Nearby, they noticed a little pool of intravenous fluids dripping onto the floor. Lisa’s bed was empty. In the treatment room, the ward manager and senior sister argued in hushed, but heated voices about forty milligrams of morphine that had gone missing that afternoon.

Calls from patients were stacking up slowly in the out of hours GP co-op, located in an annex to the A&E department. By this time, most people had given up on finding a cure for their symptoms before Christmas day and were prepared to wait until at least after the turkey and mince pies. A late cancellation by another doctor whose daughter had been admitted to hospital meant that the night shift needed filling at just a few hours’ notice. Anna had volunteered with barely a thought. It paid well, but she didn’t need the money, she did it because they needed her. She got a faint glow of satisfaction when her manager called her straight back to express her gratitude, but she shrugged it off, she was only doing her job. The same feelings of satisfaction she used to get from grateful patients barely registered any more. She wondered why.

It was impossible to recollect clearly what had happened that morning. Sally had been feverish all night and had to be woken up. They were late for her ballet class and John had been irritable and impatient getting her ready. Of course he hadn’t performed a clinical examination, he was her dad. Like a hundred or more children he had seen at work that week he’d felt sure it was ‘just a virus’. Once, about a year ago, when her younger brother had burned himself, Sally had told her father to take him to the doctor. ‘But it’s ok, daddy’s a doctor’, he had said in his reassuring, doctorly voice. ‘No’ she replied firmly. ‘You’re not the doctor, you’re daddy’. He related this to his colleagues at the time and one by one they out-did each-other with tales of broken bones, metabolic disorders, and overwhelming infections that were left way beyond what they would expect or hope from their patients. He imagined how outraged Sally would be to hear them.

Lisa left her flat in the early hours of the Friday morning. She cannot remember quite what she had intended, but imagined that she’d gone in search of something else to drink or something to jump off. Until ten days before, she had managed to continue working without fault, as the senior clinician in her department. She noted with some satisfaction that in spite of drinking the best part of a bottle of gin a day for the last 2 months she still performed better than her colleagues. An invitation to apply for the post of clinical director, almost unheard of at her age, sat with a star on it among her emails to be dealt with. Drinking, in her mind was about testing boundaries, she liked messing with her head. Her mother had schizophrenia and coped remarkably well with it and was a successful geneticist, researching her own condition – what else? Lisa explored her mind in other ways, experimenting with hallucinogenic drugs in adolescence and at medical school and then, in the interests of trying to understand what her patients had to go through, tried all the different psychiatric drugs she was expected to prescribe for her patients.

Anna’s husband and kids would all be in bed by now. She had meant to call them, but didn’t think to stop and have a break until it was too late. They were pretty understanding really, they had to be with a doctor for a mum. She wondered whether other families were less forgiving, made their medical relatives feel guilty about the all the time they spent at work, the unsocial hours and unscheduled shifts. The kids had protested in their own way, when they scrawled with crayons across the calendar, ‘mum’s at work, mum’s at work, mum’s at work …’ She had tried to make it up to them by bringing presents home after spending last weekend at a conference, but they had taken the presents and ignored her. She felt cold as she thought about it. It wasn’t just the December rain.

By 6 years of age Sally was already showing precocious talents at whatever she, or more accurately, her parents, chose. John had always felt that he could have done a lot more with his life and didn’t want Sally to grow up, plagued by his regrets. None of his family had been to university and his parents had been incredibly proud, if a little bemused when he managed it. He chose medicine, a little half-heartedly, ‘to keep his options open’. At the time, he saw it as serving an apprenticeship and having a trade to fall back on, but what he really wanted was to play football, or the guitar. A medical degree was just supposed to be insurance, but gradually, medicine took over his life. John the centre-forward and Jonny the lead guitarist were subsumed by Doctor Davis the A&E consultant. He had recently lost interest in watching football or listening to music as the stars grew ever younger and reminded him of what was no longer possible.

Lisa’s childhood had a mixture of benign neglect or liberal laissez faire and she was naturally adventurous and talented. She found success wherever she applied herself and not infrequently in places where she didn’t try. She entered medicine because she thought it would be a challenge, but found her peers intellectually dull and unsophisticated with the exception of a clique who seemed destined for psychiatry. She had a natural affinity for her work, and an easy empathetic way with patients and staff, and progressed quickly in her academic and clinical roles. She was an obvious choice to run the sick doctors programme. She quickly became very close another psychiatrist with schizophrenia who she had for a long time admired. Their professional relationship was bound by the strictest confidences, but they shared a rebellious desire to test boundaries and experiment not only with medications but their roles.

Anna’s parents separated when she was twelve, just after her mother’s second breast cancer. She never forgave her father for abandoning them after everything they had been through, while her mother was in the depths of depression and undergoing palliative chemotherapy. She cared for her mother for the last year of her life and knew from then on that she was destined to be a doctor. She quickly became disillusioned by how impersonal and scientific medical education was, compared to her experiences with her mother and the doctor she wanted to be. She wanted to right the wrongs, to re-humanise care, to make doctors talk honestly with patients and families about death and dying, to admit when care was futile, not to abandon them at their time of need. She found her home in palliative care and general practice, where she had time to build up relationships with patients. By drawing on her own painful experiences she discovered her gifts for empathy and caring.

 

We have made virtues of independence and objectivity, though it is where lives intersect that medicine is practiced. We teach doctors about clinical depression but very little about human misery and we teach them how to treat cancer but next to nothing about how to deal with the fear of death. We train doctors to be scientist problem solvers, viscera-mechanics rather than holistic practitioners who will sooner or later discover that what ails the body also ails the soul.[i] In part this is because medicine has provided us with a taxonomy of suffering according to whether it can provide diagnostic proof, therapeutic intervention or profits. What falls outside is none of our business, in the widest sense of the word. We propagate a medical persona, individually and collectively internalised, that unlike our patients we are healthy, resilient, rational and indefatigable.[ii] We proudly display our passports for the kingdom of the healthy, because secretly, we believe that the kingdom of the sick is a punishment for weakness of the will, lack of stamina or moral torpitude.[iii] [iv] Little surprise then that for too many doctors, death is preferable to being seen to be vulnerable or weak.[v] Ours is a one-way mirror, designed to protect us from our own suffering and vulnerability, but allowing us to look right through it and see in others what we fear in ourselves.

 

As they turned to go back to the hospital, they caught sight of one-another for the first time. There was something familiar about the mixture of sadness and determination. The roots perhaps of their vocation.

 

Further reading:

The Bad Doctor: The Troubled Life and Times of Dr Iwan James. Brilliant comic book delving deep into the life of a GP.

The Emotional Labour of Care

Do Doctors need to be kind?

References

[i] Kennedy I. Reith Lectures: 1980 Unmasking Medicine Lecture 2: The New Magicians

[ii] Zigmond D. Physician Heal Thyself: The Paradox of the Wounded Healer http://www.marco-learningsystems.com/pages/david-zigmond/physician-heal-thyself-3.htm accessed 28/02/2014

[iii] Sontag S. Illness as Metaphor and AIDS and its Metaphors. Penguin Books 1983

[iv] Wallace J. Mental Health and Stigma in the medical profession. Health (London) 2012 16: 3

[v] http://www.kevinmd.com/blog/2014/02/doctors-commit-suicide.html Accessed 28/03/2014

Transforming the culture of healthcare: Sick doctors and the GMC

Originally posted on the Centre for Health and the Public Interest

 

Two recent reports from Civitas and UK and international researchersabout the treatment of doctors under investigation by the GMC raise very serious concerns. Their findings can be summarised in a quote from recent chair of the Royal College of GPs, Clare Gerada, in her capacity as a director of the Practitioner Health Programme – an organisation that provides confidential care for sick doctors:

‘The GMC is “traumatising” unwell doctors and may be undermining patient safety.’

Doctors are traumatised by a lack of support and help with personal illnesses, intimidating communications, and excessively prolonged and poorly handled investigations.

 

Few doctors would seriously doubt that investigation by the GMC is extremely stressful. A powerfulpersonal account from Dr Shibley Rahman illustrates the devastating consequences of a failure to provide support during an excessively prolonged investigation of an obviously sick and vulnerable doctor. Ninety six doctors died while under investigation by the GMC between 2004 and 2013. It is likely that some of these deaths were suicides but an investigation announced by the GMC last September has yet to be published. The Civitas report concludes that the GMC and NHS employers are failing in their duty of care to sick and vulnerable doctors and this is a risk to the safety and quality of patient care.

 

Nevertheless the report leaves out a lot of evidence that can strengthen their case for reform. Just culture and patient safety, kindness and compassion and patient-professional partnerships are vital components of a culture of care that includes both patients and professionals. Doctors’ health is threatened not only by the regulatory and disciplinary culture of the GMC but also a pernicious regulatory, target-driven NHS culture and the pressures of ever-increasing workloads in a climate of inadequate funding, under-staffing and increasing competition.

Just culture

 

A just culture is one in which people are not afraid to admit mistakes because they are confident that they will be dealt with fairly. Recommendation 86 of the 2001 Bristol inquiry states:

‘The culture of blame is a major barrier to the openness required if sentinel events are to be reported, lessons learned and safety improved.’

The Francis report 2013 quotes Liam Donaldson:

Honest failure is something that needs to be protected otherwise people will continue to live in fear, will not admit their mistakes and the knowledge to prevent serious harm will be buried with the patient.

The Berwick report into patient safety begins:

‘Abandon blame as a tool, NHS staff are not to blame – in the vast majority of cases it is the systems, procedures, conditions, environment and constraints they face that lead to patient safety problems.’

When airline pilot Martin Bromiley’s wife died in 2005 during a routine operation he wanted to find out what happened:

‘…he assumed that the next step would be an investigation – standard practice in the airline industry after every accident. “You get an independent team in. You investigate. You learn.” When he asked the head of the intensive-care unit about this, the doctor shook his head. “That’s not how we do things in the health service. Not unless somebody complains or sues.” ‘

This captures so much of what is wrong with how we deal with errors and complaints. Bromiley set up the Clinical Human Factors Group with just culture at its heart.

 

The ability of patients to speak up and share their concerns about care is also vital for safety and they need to be able to express their concerns, and complaints if necessary, without contributing to an adversarial culture. The GMC at present is contributing to an adversarial culture in which doctors are afraid to admit their mistakes.

 

Doctors as victims

 

The emphasis in the Civitas report is on doctors as victims, not only of the excessive and bungling efforts of the GMC, but also of vexatious patients or employers, an intrusive and salacious media, and unaccountable users of social media and feedback websites. We should be very wary of implicitly blaming patients. On page 11, they claim that the rhetoric of patient entitlement and choice has contributed to ‘a massive escalation in cases dealt with by the GMC‘.

 

A report from Plymouth University commissioned by the GMC showed that complaints are fuelled by traditional media’s portrayal of ‘bad doctors’ and facilitated by social media. They describe the considerable public confusion about complaints procedures that is leading to complaints being made to the GMC that ought to have been dealt with locally without escalation. In common with the Civitas report, they found ‘a general perception that the nature of the doctor-patient relationship has changed, with patients becoming less deferential, better informed and more willing to question the care they receive.’

 

The authors of the Civitas report appear to view this as a threat (page 33/34), rather than an opportunity. There are a considerable number of doctors like myself and patients who use social media to challenge one another and the wider goals of medicine and health policy in a spirit of enthusiastic curiosity. There are vigorous and encouraging debates challenging medical paternalism and the notion of doctors as victims. The Kings Fund and the BMJ are doing excellent work with patients as partners. Shared decision-making between patients and professionals is not only a philosophical/moral position that challenges medical paternalism, but has a rapidly growing evidence-base and an NHS websitePatients’ preferences matter and so does good communication.

 

The rose-tinted view of the competent, skilful doctor who ‘lacks empathy and wastes little time on social niceties‘ as the innocent victim of unreasonable complaints (page 33) doesn’t stand up to the evidence above linking good communication with appropriate clinical decision making, nor the importance of kindness in care. Patients have every right to want to be treated kindly and involved in decisions about their care and doctors (even older, male surgeons) can do this.

 

Wider cultural issues

 

The extent to which the activities of the GMC are responsible for doctors’ distress is important and under-appreciated. The authors of the Civitas report are absolutely right to draw our attention to the sad fact that the GMC is not providing support where is needed and is almost certainly contributing to the problem. Nevertheless there are many other important reasons for doctors’ distress at present, some of which will increase the likelihood of a doctor being reported to the GMC.

 

Surgeons and physicians who make errors are badly affected even without being investigated. They tend to blame themselves and are more prone to burnout and future errors. Burnout is a serious issue among doctors, and recruitment to general practice has reached crisis point. The government policy of naming and shaming GPs who are below average in diagnosing cancer adds to our despair. Increasing competition at a time of austerity in hospitals leads to them being castigated for ‘failing’, leading to a spiral of decline, demoralisation, and cultural drift. Work pressures and poor management identified after Mid Staffs remain a serious cause of stress and illness for many NHS staff who are under increasing pressure to work when they feel unwell. All these factors are undermining the good health of professionals on whom patients depend.

Conclusions

 

It is essential that patients are protected from doctors whose behaviour puts them at risk, but we need better preventive as well as treatment measures and we need to minimise the harms when GMC involvement is necessary. Professional isolation and a lack of insight correlate well with under-performance and better support and teamworking, for example through coaching and mentoring can help.

 

This is a very important report with implications far wider than the treatment of individual doctors by the GMC. It is the interests of patients that doctors caring for them are cared for themselves. Added to evidence about just culture, patient safety, kindness in healthcare and doctor-patient relationships – this should prompt a significant cultural shift towards much more compassionate relationships between institutions, professionals and patients which will benefit us all.

 

Further reading

Ballatt J, Campling P. Intelligent Kindness: Reforming the Culture of Healthcare. RCPsych Publications 2012

Anthony Cooper QC to probe GMC investigations of former whistleblowing doctors. HSJ 01.08.2014

Where do we start? Evidence-Based Medicine and antibiotic prescribing.

Fahima was my third patient of the day. I was running almost on time and relatively unstressed.

She bought in two of her children with her, and opened the consultation by saying that she had made the consultation for herself, but now the girls were ill, so she wanted  me to see them instead. This happens quite a lot. I also have patients cancel or fail to attend appointments if they feel too ill to attend or refuse home visits if they don’t feel well enough to make themselves or their homes presentable.

Like many GP practices, we still have ten minute appointments for each patient even though they might have one or several, straightforward or complex complaints. Now there are two, or possibly three patients who may have three related or otherwise, simple or ill-defined problems to work through. Medicine is a practice that continually involves decisions about what to do in unexpected situations like this.

The practice of medicine is cultural, social and philosophical and far more besides being scientific or ‘evidence based’. My decision to attempt to deal with Fahima and her daughters in a single appointment is in part driven by anxiety, ‘what if I miss something serious?’ In part it is pragmatism, ‘I’m pretty certain they’re here with straightforward, related complaints – in fact, they all appear to have colds, I know them and I can hopefully deal with them effectively in the time I have’. I hope that I can use the opportunity to invest some time exploring Fahima’s concerns, that might then reduce their likelihood of attending with the same problem next time. It’s also moral, ‘I’m the kind of doctor that helps patients when they need me, so I’m not going to send them away to book another appointment with another doctor or go to A&E’. These decisions, conscious, but implicit are also evidence-based. There is evidence that continuity of care and exploring parental anxiety improves the safety and effectiveness of care. But I also happen to be the kind of doctor that feels guilty for making subsequent patients wait when this consultation takes longer than ten minutes, and I wonder how harmful this might be.

I know Fahima and her daughters well. I know that her husband used to beat her and they were separated but now he has come back, and though she denies it, I’m not sure he isn’t beating her still. Social services are involved. I know that she has struggled to look after her children, that they are under-nourished and have both been in hospital with chest infections and their asthma and eczema is under-treated despite input from community paediatric nurse specialists. I know that Fahima has panic attacks and her oldest daughter Aisha, who is only 9, has missed school a lot to look after her mother. They have a constantly changing stream of relatives and relative-strangers in their damp, two bedroom flat, many of whom sit up at night, smoking and playing cards with their dad. I’m wondering how ‘evidence-based medicine’ can help me here.

The modern pioneer of evidence-based-medicine (EBM) David Sackett, described EBM in 1996 as the integration of individual clinical expertise with the best available external evidence and the patient’s values and expectations. 

EBM = clinical expertise + external evidence + patient values/expectations

Sackett was well aware of its limitations,

Without clinical expertise, practice risks becoming tyrannised by evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient.

There is a now a critical campaign for a renaissance of ‘real EBM’, headed by Prof. Trish Greenhalgh. According to these critics, the evidence in EBM is misappropriated by vested interests, excessive in volume, of dubious significance, unreliable in the kind of complex patients seen in practice and management-led rather than patient-centred. All of which might be true, and I suspect they are right. After all, doctors are not very good at understanding the statistics on which most evidence is based, and it does seem that evidence is still seen by many health professionals as being authoritarian rather than facilitative. But evidence is only one part of the equation. Much of their criticism focuses on the unreliable external evidence squeezing out clinical expertise and patient values. There may be more fundamental problems.

For one thing, it’s not clear why clinical expertise is on the right side of the equation – as if it is somehow separate from evidence and patient values rather than the ability to integrate them. Why not,

Clinical expertise = external evidence + patient values?

More importantly though, patient expertise and clinician values are excluded despite it being obvious, if under-appreciated that patients are experts and clinician values influence care. Greater attention to clinician values and patient expertise is almost certainly key to understanding variations in care.

A better formulation might be,

Clinical practice is the integration of the best evidence with the combined values and expertise of patients and clinicians.

The degree to which the expertise and values of both parties is drawn upon varies considerably according to changing contexts such as how strongly values are held and how much expertise each party has, or is willing to share. Many patients have strong opinions for or against antibiotics, and some have suffered unusually severe throat infections that take significantly longer than average to resolve and know from experience that antibiotics are effective.

Qualitative research can help to reveal hidden values and expectations. In one study from 1976, GPs were found to be far more likely to prescribe antibiotics if they expected patients to have difficulty getting to the practice, if they had an exam or travel commitments the next day or if a sibling was in hospital with pneumonia. I used to look after an opera singer who expected antibiotics within hours of every sore throat, and was very upset when I attempted to challenge this. I was relieved to read in a study published this year that I wasn’t alone in prescribing antibiotics to avoid an unpleasant confrontation with patients. The same study raised the point that GPs tend to over-estimate how often patients want antibiotics and perhaps we expect conflict too often. Almost certainly if we are stressed this is more likely.

Stress and burnout is a serious problem among GPs and is associated with a reduced ability to tolerate uncertainty, for example the point at which an antibiotic prescription may be appropriate. Many GPs will admit in private that they are more likely to prescribe antibiotics at the end of a busy clinic that is running late than at the beginning of a clinic that is running on time. In part this is because prescribing is quicker when delivered with, all you need to do to get better is to take the pills, rather than explaining why antibiotics are not required and discussing how else the patient (or parent) might mange their symptoms. Obviously conversations about what else can be done should happen whether or not a prescription is issued and discussions about why antibiotics are prescribed are just as important as discussions about why they are unnecessary. A point we are well aware of but might skip over in order to keep to time.

One way that doctors try to avoid conflict is to use the clinical examination to build a rapport with patients and the strength of the rapport influences whether they are able to take control of the decision to prescribe. The clinical examination is often used as a time for reflection or an opportunity to uncover a patients’ hopes and fears. In another study from 2002, GPs who were least likely to prescribe were more likely to be older, to spend longer with patients and be more interested in their relationships with patients. Those who prescribed more often described their role with patients in terms of a ‘professional service’ or a business exchange. Interestingly they were also more likely to describe themselves as being ‘firm believers in evidence based medicine’ than their peers who prescribed least. Low cost prescribing doctors had a more relaxed attitude to evidence, being less likely to attend educational meetings and were less concerned with labelling symptoms with a diagnosis.

Continuity of care enables doctors and patients to get to know and trust each other and also increases the likelihood that antibiotics will be prescribed prudently. Continuity and mutual trust can make a brief consultation successful, but lack of continuity can eliminate the effects of knowledge and professional skills. One reason parents expect antibiotics when they, or their children have a cold or a sore throat is that they lack confidence in their ability to cope. A known and trusted doctor is more likely than a stranger to give them the confidence they need.

All of this takes place in a wider social context. I am only able to make a decision that combines evidence, expertise and values if there is a meeting between myself and Fahima and her children. A system of healthcare that enables people to see a GP without charge, when they need, makes this possible. The culture of my GP partnership values timely access and continuity of care and allows doctors the autonomy to see extra-patients where necessary and the time required to discuss values and share expertise. We provide protected time for supervision to help reduce the risk of burnout and give staff the opportunity to discuss difficult cases.

In a broader social context, national culture has a significant influence over decisions to prescribe antibiotics as well. A Dutch GP working over here thinks we’re terribly laissez-faire but we point out that we prescribe less than half as many antibiotics as the French.

Antibiotic prescribing rates by country

Why we prescribe antibiotics matters because of the growing problem of antibiotic resistance, where bacteria previously sensitive to the effects of antibiotics develop resistance as a result of excessive exposure.

If we think we (or the French) are to blame, then we need to look also at what is happening in developing countries. I have worked in Afghanistan, Nepal and India with doctors and nurses whose careers have taken them all over the world. A very common situation is as follows. A poor person goes to see a doctor or other healthcare professional with a cough. The ‘professional’ assesses their ability to pay for treatment and gives them a scrap of paper with a list including antibiotics, pain-killers, vitamins, antihistamines and possibly more and sends them to their brother’s pharmacy where they buy whatever they can afford. Often they won’t complete the course of antibiotics, so they give (or sell) them to someone else. In many, perhaps most poor countries it is possible to buy antibiotics direct from pharmacies, and during the avian flu panic a few years ago there was a roaring trade in antiviral drugs being sold from online pharmacies in rich and poor countries. The widespread use of antibiotics and antiviral in intensive livestock farming is also alarming. In the case of TB (tuberculosis) the problem of resistance is significant because antibiotic treatment has to continue for several months and is frequently interrupted by conflict, natural disaster and so on. Medications are frequently sold or exchanged for other medications, food, etc. Unsurprisingly totally drug resistant TB is now, officially a thing.

I don’t wish to ignore the  enormous efforts to circumvent these problems with directly observed TB treatment programs and attempts to provide Universal Healthcare Coverage in poor countries, but the damage is being done all the time.

The future for prudent antibiotic prescribing at home isn’t much brighter. A political agenda that is aggressively encouraging patients to consume and professionals to compete and be judged according to superficial measures of patient satisfaction, combined with a loss of continuity of care and the premature retirement of older GPs is worrying to say the least. External evidence – about when antibiotics should be prescribed-  is occupying too much attention in our efforts to make medicine more ‘evidence-based’.

Back in my own surgery I am faced with Fahima. Her experience of healthcare in Turkey was that colds were quite frequently treated with antibiotics and other medicines and it has taken me about two years to build the trust necessary to convince her that she and her children can manage without them. Nevertheless she is very anxious, both children have been sick recently and I had seen one of them with symptoms of a cold about a week before they were admitted to hospital with a chest infection and her confidence in my diagnostic skills has taken a blow. In fact my confidence in myself took a knock after that. She spends most of the allotted appointment time complaining about the overcrowding at home and how much it is contributing to her children’s ill health so we have almost no time to discuss the use of antibiotics. Most of the conversation takes place as I examine them all one by one, on the couch. I’m examining their behaviour as much as I am their lungs. When the examinations comes to an end, I am prepared to talk about antibiotics and self-care, even though I am running late, but Fahima is gathering her bags and getting ready to leave,

“They’re OK? Yes?” she asks, with her hand on the door.

“Yes, they’ll be fine” I say, taken by surprise.

“Thanks doctor, thanks for listening”

 

Update

05/08/2014: Public Health England study into antibiotic prescribing in General Practice