Dr Avril Danczak
Choosing wisely – can we avoid the ‘computer says no’ scenario?
Choosing Wisely emphasises avoiding investigations or treatments of limited clinical value. However, decisions are made during consultations. Metcalfe memorably referred to consultations as the crucible of daily practice; a small robust vessel, heated to transform the materials within.¹ Consultations are intense encounters, with pressure to change the base metals of uncertainty, lack of information and conflicting expectations into the gold of a shared management plan. Can wise choices still happen in conflicted situations?
Take Mary, age 52, who strides into my Surgery. “I fell over on my back two weeks ago, it’s still not better, so I need a back X-ray find out what is happening” she says firmly, determined to get the referral she came for. Consultations that start this way are not always easy. Suspecting the request is not likely to be the best course of action but not conceding to an inappropriate referral is not always straightforward in a 10 minute consultation. Is avoiding conflict with a resolute patient and not simply giving a ‘computer says NO!’ answer possible?
Of course, as GPs it is up to us to build a good rapport, ensuring our patients are, and feel fully understood and cared for. For Mary this meant starting at the beginning, how she sustained the injury and how she felt. Briefly distracted, she had tripped and fallen in a busy station. There was some bruising (now all gone) but she was able to walk, and go to A&E where she was told she was just bruised. She only ever had pain in the area of bruising, which had now reduced in intensity. There were no other symptoms, and she was functioning normally. My examination of the back and legs showed everything was normal and recovery was progressing as expected. There was no reason to do a back X-ray and every reason to watchfully wait for complete recovery.
Asking how she felt after the fall Mary became animated; it had been embarrassing to fall in front of so many people, she felt foolish. She had found the A&E care efficient, brusque even, which reduced her trust in the clinical assessment.
Empathy, praising her stoicism, acknowledging her worry that the initial assessment was not complete put Mary’s experience at the centre of things. Giving Mary advice and rehabilitation suggestions showed my commitment to her future progress. So what questions remained for Mary? Half expecting a repeat demand for a scan or an X-ray, none came. She thanked me for my time and left as confidently as she had entered.
Clinical care depends on the meticulous application of this basic principle; the disease narrative must be melded with the patient’s illness narrative.² Physical issues must be set in the context of their effects and meaning for the patient, understanding concerns and fears. Accepting different expectations while sharing the clinical reasoning and decision making process overtly, can build a relationship in which the patient may not get what they initially thought they came for, and yet remain happy.
Consultation competencies that develop trust, rapport and mutual understanding bring a full appreciation of all aspects of the patient’s story. The rewards of using such skills are huge; accurate medical diagnosis through improved listening, a better doctor patient relationship, smoother negotiation of care and the job satisfaction that results makes doctors less stressed. ‘Computer says no’ consultations are avoided. These skills do not come easily; practice and feedback are required. In one California health service, communication training is mandatory for all newly hired doctors: better decisions and fewer malpractice claims are the result.³ Should we all update our consultation skills training every year, just as we do our CPR skills? After all, most of us see patients more often than we perform CPR!
1. William Pickles lecture 1986. The crucible. Metcalfe, D British Journal of General Practice 1986 vol. 36 no. 289 349-354
2. Silverman J, Kurtz S, Draper J (2013) Skills for Communication with Patients. CRC press
3. http://healthcarecomm.org/case-studies/kaiser-permanente [accessed 16 December 2016]