Views From The Front Line

Dr Chris Van Tulleken

The Choosing Wisely campaign – aimed at improving conversations between patients and clinicians – is the cultural change that is desperately needed on both sides of the consultation desk. The ambition seems so simple and obvious that to state its importance feels almost banal. But trying to put it into practice is not so simple.

In 2016 when I made a program called “The Doctor Who Gave Up Drugs” for the BBC. The premise was simple: I would run a clinic in a general practice which aimed to take patients off unnecessary medication and I would treat them with evidence based alternatives. In other words I would put into action the principals of Choosing Wisely and the patients would, in turn, cast away their drugs and rise like Lazarus to new lives of wellness and joy. My plan was simply to talk to my patients, explain the evidence around the drugs and their side effects and the near miracle benefits of my other activity-based interventions including walking, cold-water swimming, Kung-Fu. Together we’d reach a decision about what was best for them.

But medical consultations have a rhythm and a flow well known to, and expected by, both parties: “what seems to be the trouble? … ” A few questions followed by a prescription or a referral. When you deviate from this pattern even slightly it can feel uneasy.

From the patient perspective not everyone is happy to discuss the risks and harms of their current treatment. They may not be expecting to be ‘empowered’ or to ‘take charge of their illness’ and the initial stages of these processes can feel like a shifting of responsibility that is not “what they came to the doctor for.”

Likewise, for doctors, a change may not be easy: a better conversation is a more honest one and this may be scientifically and technically challenging. Many interventions have vast and complex data sets which don’t always showcase their shortcomings and side effects as well as their more tangible benefits. But an honest conversation is also more socially difficult. Implicit in many patient interactions is the idea that a treatment can quickly help without doing any harm. So whether the discussion is about years of opiates for chronic pain or a short course antibiotics for a viral infection unravelling the evidence and alternatives, without generating anxiety or frustration, takes time, trust and preparation on both sides.

Choosing Wisely is the best template for these conversations but we shouldn’t underestimate what a cultural shift these seemingly simple changes represent. Equally we shouldn’t underestimate the benefits that Choosing Wisely could bring; it is a revolution in healthcare waiting in the wings. More than any new technology in the pipeline it has the power to save lives and to create a health service that actually improves health. It also offers the only hope we have for bringing costs back under control.