Tuesday, 31 May 2011

A philosophy of medicine

I have a vivid memory of standing in the Tate Modern a few years ago, looking at a blank canvas that had had a gash slashed into it. The card next to it read ‘Fontana first slashed a canvas with a razor blade in 1958, but he had been making holes in them since 1949.’

This struck me as an extraordinary waste of good canvas, and a poor use of nine years. For many years, the sense of exasperation prompted by that card, and Luciano Fontana’s vendetta with perfectly good canvas summed up my attitude to modern art.

Naturally, I was missing the point. As I wandered around the Miro exhibition at the weekend, looking at paintings that still didn’t speak to me particularly loudly, I realised that I have often misunderstood artistic movements as being purely about the artistic products; I always thought that the debate and arguments that underpinned art were incidental to the pieces of work being produced. Miro helped me to realise that this is not true, that it is sometimes the debate that defines the movement, and that through their art, artists are engaging in true philosophical debate. Understanding the context in which art is produced informs one’s enjoyment of that art, more than simply willing the pictures of sculptures to speak to you.

As I was wandering around, starting to understand the influence of the Spanish civil war, and the struggle for a Spanish Republic on MIro’s work, I began wondering what my philosophy of medicine is, and how this fits in with the world of medicine in which I work.

My own views have undergone significant revision in recent years, and one of the dominant features of my philosophy of medicine is patient-centredness, which I think can be summed up as an approach to medicine in which technical expertise, communication and customer service share equal importance.

Let me take a moment to explain what I mean: one of the red lines of medicine is that the quality of care must measure up to generic standards. In practice, this is not always true, but as I have pointed out in other blogs, patients often do not know whether they have experience good medicine or bad, so ensuring that good practice is the norm is our responsibility.

Secondly, communication is one of my pillars of medicine: individuals deal better with experiences when they have a good idea of what is going on. The challenge of communicating the complexities of medicine and helping patients navigate their way through the experience and the system is a key aspect of good patient care.

Finally, customer focus (perhaps a clumsy term) highlights the importance that I place on designing services around patients and their needs. Too often patients are expected to know how to use complex health services and can even be criticised for not using services ‘properly’. By setting up the system to match both patients needs and patterns of uses is a important factor in patient satisfaction, and part of our obligation to provide comprehensive health care services for the populations that we serve.

I recognise that many other philosophies of medicine abound, and there is nothing particularly ‘right’ about mine. However, there is one particular view that I see often, that worries me. I call this the philosophy of professional self-interest, which can be summed up as the viewpoint of the doctor who always bemoans that new doctors know how to communicate with patients, but do not know what to communicate with them, because they do not ‘know anything’, and who complain about patients expecting more than they should from the health service on offer. This is a caricature, but I hope you know what I mean - they are the people for whom medicine is a technical and intellectual challenge (they want to be the expert in one disease or treatment for example). They are the medical practitioners who resist the idea that medicine has changed - we have a greater range of diagnostic procedures that negate some of the finer points of clinical assessment, and we have better informed patients with higher expectations. The complexities of clinical care are difficult for one individual to master, and the approach to medicine is inevitably more dependent on groups of people working together.

Necessarily, our approach to medicine needs to change to meet these different demands, but it often seems to me that doctors hold on to an old fashioned approach to doing things. We congratulate each other for knowing what Traube’s sign is, and offer criticism for not picking up Corrigan’s sign, even though we all know that the patient will have an echocardiogram anyway.

So my message today is that we should be clear with ourselves about what we think is important in medicine. I do not necessarily want you to agree with me, but I would be chuffed to bits if I could persuade that it is ok to imagine a different way of doing things, and to set out to chase your vision.

Friday, 20 May 2011

Everyone's talking about love (or the parable of Lennie and the puppy)

Just like David Cameron, I love the NHS. I love the way that whenever I deal with a patient, we can talk about what we are able to do to help with their medical problem, rather than what they are able to afford. I love the way the NHS evens out the peaks of affluence and the troughs of poverty.

But I don’t really want to play a game of who loves the NHS the most - that really doesn’t get us anywhere. What helps is to examine how well the NHS serves its patients, and what it can do to serve patients better.

I used to think that because the people who tend to use the NHS the most are the people who contribute the least (poverty is associated with poorer health) they should feel lucky to get the service they do, and they should accept the level of service on offer. This view was in part driven by the misery of being an A and E SHO, where the relentless, thankless toil of being at the sharp end of emergency services can really test one’s resolve. Objectivity suffers under those circumstances.

My views are different now, partly through maturity, partly through better insight into what it is like to be a patient, and partly through having the time and space to really reflect on what is important in healthcare. One of the conclusions I have come to is that as doctors, while we are expected to be technical experts in managing disease, we should also try to be experts in managing patients through the often frightening experience of being poorly. While very few of us actually know what it is like to suffer the conditions that we treat everyday, we have the ability to help patients and their relatives know what they can expect. For many, it is the uncertainty of illness that is often the hardest to bear, and the uncertainty of what the diagnosis means. Often my patients don’t know whether they have experienced good medicine or bad, but they do know whether they have been treated with dignity, courtesy and candour.

But where am I going with this? Well, a couple of days ago, during a discussion at a Geriatric SpR training day, I remarked to one of our speakers that I often found that when I was  discussing a patient’s clinical care with other doctors, particularly in other specialties, the conversation was not always driven by the clinical needs of the patient, but rather it felt as if it was being influenced by any number of other interpersonal factors; my point was that as doctors we need to be honest enough with ourselves and each other to acknowledge that the way we do things isn’t always driven by the priorities of patient care, and that we often bring a lot of ourselves into our interactions with work. I think I closed with some remark that medicine is a customer focused industry, and we need to remember this sometimes.

This standpoint was later contested by one of the registrars in the room, who argued that users of the service had an obligation to use it properly, for example by remembering that on weekends there is only a skeleton staff, and the same level of cover cannot be offered. Her point revolved around the viewpoint I outlined at the start of this piece - that the health service provides a level of cover that patients are lucky to have, we all pay taxes that support it, that we work jolly hard in providing it, and that it cannot always be organised around the convenience of the patient.

Now this is a complex field and I am not planning to iron all of this out today. But it did remind me of the many occasions I have heard doctors complain about patients presenting to A and E rather than going to see their GP. Sometimes (particularly as an A and E SHO) I have real sympathy about this. But the health service is a complicated beast, and navigating one’s way around it can be very hard. It doesn’t matter what community initiatives, or GP consortia or out of hours services there are in your borough, the one constant of the health service is that A and E is always there, and it is always open, so it is no wonder that when something happens to someone that is subjectively important to them (but not objectively serious to us as doctors) that their decision making brings them to A and E.

And this is my point today - we love the NHS, and when someone tries to change it, it can feel like the essence of the thing we love is being questioned. But just like Lennie and the puppy in Mice and Men, our love is not always helpful, particularly when it blinds us to the things that the health service could do better: it could be easier for patients to know where to get the right help, it could be better at arranging services around the convenience of patients, and we could all be better at being experts in managing patients through the experience of ill health.

Sunday, 15 May 2011

Patient autonomy, and the 'wrong' decision.

The concept of capacity is easy to understand but often difficult to put into practice. Judging whether someone has the ability to make a decision for themselves can be tricky, and watching how different people go about it says a lot about their views on the role of the doctor and the importance of patient autonomy.

In assessing someone’s capacity to make a decision, all you have to convince yourself of is that they understand the information that is relevant, and that they are able to retain this information for long enough in order to make an informed decision based. That seems simple enough, but in practice, this straightforward assessment is easily obscured by other factors.

In particular, it can be difficult to support someone who has made what we think is a dangerous or foolish decision, even though they may have clearly demonstrated the capacity to make this decision. It is not for us to judge the wisdom of someone else’s personal choice. Also, capacity has to be assessed on decision by decision basis. I often hear sweeping statements that patients do not have capacity. Full stop. Blanket statement. In much the same way as we assume a suspect is innocent until proven guilty, we must assume that someone is able to make a decision, until we assessed their capacity for the specific decision at hand, and having taken all necessary steps to help them make the decision for themselves. This can be time consuming, and it is often tempting to take short cuts, but I was reminded of the importance of doing it properly when dealing with one particular patient recently.

The gentleman in question was an articulate, intelligent man of 70, who had suffered a significant illness, resulting in a sudden and severe reduction in his physical function. We had great hopes for improvement, and were looking forward to supporting him through his rehabilitation in hospital.

One afternoon, however, he told me that he had arranged for his wife to come to the hospital that afternoon with a couple of heavies, and take him home. He had made his choice, and he was happy with that. I pointed out the impact this might have on his physical recovery, and how he did not yet have any of the equipment he needed at home, and the hazards that this might subject him to. He retained this information, he weighed it, and then he politely declined our help, preferring instead to take his chances at home.

It’s hard not to make a judgement about a patient when they make a decision that completely ignores your recommendations. Foolish? Yes. Wrong? No. Dented professional pride? Definitely. But, it’s not about me is it?

When I asked him what his reasons were, he told me that he did not believe in empiricism, or a rational actor paradigm. In fact there is no such thing as an objective reality. So when I told him that we would be able to help him recover on our rehabilitation ward, his world view told him that he would be able to undergo the same kind of recovery at home, using his strength of will and imagination.

He made me question whether, in a medical world that invokes evidence base, empiricism and objectivity, are we honest enough to admit that many of the decisions we make are not actually as objective as we claim them to be?

A chap called Jack Dowe has made exactly this argument, pointing out that when we make a clinical decision, our failure to wholly separate ‘deciding’ from ‘doing’ means that we only ever take the evidence into account. His proposal for a formal process of modelling and structuring decisions (called Decision Analysis Based Medical Decision Making) is cumbersome and clunky, and clearly has never been anywhere near the hustle and bustle of a busy on-call shift, but it raises an important point for all of us: whenever we make a decision, there is something of ourselves in that decision. The evidence we cite rarely covers all the particular aspects of the individual patient we are treating, and inevitably, there is a certain amount of judgement involved. And where there is ‘judgement’ there is always the risk of bias and prejudice.

There’s a passage in Gormenghast, where a group of dusty professors in Titus Groan’s school sign up to an existentialist way of thinking very reminiscent of my patient’s, based on the premise that human experience is what the mind allows it to be; love, pain, fear and so on are all subjective phenomena, and they only occur when the individual wills them to. However, when the ringleader of this group of teachers dies, one of them admits that when he burnt his arm, it actually hurt like hell, although he didn’t admit it at the time. One by one, the rest of them admit that this belief system they were bullied into following by their late colleague is actually bunkum.

But as doctors, our role is to treat patients in a manner that fits with their way of doing things. This might feel like it is hard to do when we find ourselves supporting decisions that we do not agree with, and while my patient  represents a fairly extreme example, he was a useful reminder that sometimes doctors hide behind a facade of empiricism that fails adequately to acknowledge the degree of uncertainty involved in medical decision making. Remembering this can be a useful tonic for medical arrogance, and the importance of respecting patients’ wishes.  

Monday, 9 May 2011

What's it all about, really?

The news channels are filled with chat about the Health Bill. Having just woke up from a kip after a night shift, this struck me as odd, as I am pretty sure that the nature of the debate I was hearing was stuff we were all talking about a month ago. To my sleep deprived mind, I could not work out how this had made it back to the agenda.

As with many things the answer came via Twitter, from @katycheema who told me ‘after last week's elections, the health bill is the figurative playground where everyone is chanting 'fight, fight'. Spot on.

It should be interesting, and now that  the matter is in the media, there is a good chance to put forward ideas about how the health bill should be altered to meet the needs of the public better. I know that the Department of Health has opened up a forum for sharing ideas about what should happen (http://healthandcare.dh.gov.uk/listening-exercise-how-to-get-involved/), and the challenge for all of us, now that we have managed to get others to listen to our concerns about what is wrong with the health bill, is to provide suggestions to how it should be altered - the no-change option ceased to be an option months and months ago.

I don’t want to influence your views on what should and shouldn’t happen now, but what I would like to do is to remind you what it is all about. The language of the debate about the Health Bill has often been funereal, with the death of the NHS being a consistent theme. But this has always worried me a little, because the goal is not necessarily the protection of the NHS per se, but rather the preservation of the principles of comprehensive, effective healthcare, free at the point of use for our population. I know that I have just rehashed the guiding principles of the NHS, but my point is that the NHS as we know is one way of meeting these ambitions, and if a better way of achieving these goals comes up, that involve fundamental changes to the organisation and structure of the NHS that make it unrecognisable from it previous form, then that in itself is not a bad thing. The goal is patient access, outcomes and experience,
Sometimes the resistance to change is simply resistance to change, rather than a focus on what the health service is trying to achieve.

From one on-call shift, one can see that however hard we all work, the NHS does not always put the patient at the centre. What is interesting is that it is so easy to allow patient care to be influenced by factors other than what is best for the patient. A number of times over the weekend, I found myself debating the best treatment for patients with other doctors, and realised that the nature of our conversation had almost precluded the argument being concluded on the merit of clinical arguments. The main factors at play were intellectual tussle (who could generate the best argument - a particular hobby of mine, aka intellectual masturbation), interprofessional rivalry (who has the most kudos), overwhelming tiredness, pride, and uncertainty combined with reluctance to admit uncertainty (see the first factor). I am happy that in the end, all of my patients received a good standard of care, but I had to be on my guard.

Politics is a daily reality wherever one works, but it seems to have an embarrassing salience when it occurs in the context of a patient’s care. The familiarity of other people’s sickness and fear undermines its resonance, but we fail in our roles if we ignore it: so much of healthcare is about the memories people take away from their experiences in hospitals. Most of my patients do not know good healthcare from bad, but they do know whether they have been treated with compassion, respect and dignity.

So when you’re thinking about how the Health Bill should be changed, remember that it is all about the patient - their outcomes and their experiences. And do not be afraid of dramatically changing the NHS if it helps us improve both.

Tuesday, 3 May 2011

Inspiration in an unlikely place

Last weekend, while trying to pretend I wasn’t watching the Royal Wedding, I was genuinely distracted by an unlikely thing: an article by former footballer and Ipswich manager Jim Magilton. For those of you who don’t know me, sporting nirvana is the annual clash between Wales and England on the rugby field. Despite a rather plummy accent, I am in fact half Welsh, and rugby is a passion. Football usually fills me with horror - the spitting, the histrionics, the way they treat the referee. You know what I’m talking about. This doesn’t happen on the rugby field. A good example of the standards of behaviour we expect from our rugby players are well captured by what happened to Gareth Thomas (Welsh rugby legend) after he announced that he was gay: while he may have expected a roughing up from both colleagues and opposition, what he got was the confirmation from his team mates that they had known for ages, and quite frankly, they weren’t sure what all the fuss was about. Now some of this is middle class gentility, but nonetheless, I watch rugby with the confident knowledge that while these chaps may take chunks out of each other during the match, afterwards they will have a chat and a pint (or perhaps these days, it might be an isotonic drink).

So I was quite surprised when I read something insightful and pointed about the nurture of leaders coming from football, where Alex Ferguson has written the text book they all use, and dealing with a problem is defined by how loud they shout at the person to blame. Talented footballers are asked to become managers, while learning on the job, and using nothing more than force of personality to drive them through. Jim Magilton makes the point that footballers aren’t taught how to run the business, manage players or how to run a board meeting. Those players who do manage the transition successfully often do so after a period of apprenticeship under an old hand.

This story resonated with me instantly for its personal relevance: my experience of registrar training has always focused on clinical skills and knowledge, and training in leadership has consisted of learning from the example of consultants, with the in-built assumption that we will be able to both distinguish good examples from bad, and be immune to the influences of negative role models. Judging from the process of socialisation I have seen so many of us go through, from eager idealist to cynical negativist, I am certain that trainees need more guidance on this issue. And this is not a problem that affects just surgeons - it is endemic.

On numerous occasions I have attended conferences which highlight the value of junior doctors as future, and indeed current leaders, but I think we need to be more demanding about what leadership actually entails. Doctors are certainly the technical experts in patient treatment, and this often is assumed to mean that they hold natural authority within hospitals. Often the concept of leadership that prevails is in itself unhelpful. I asked one SHO what leadership meant to him, and he told me that leadership was the skill of getting people to agree with you, and follow you. If this view of leadership is common, and I think it is, then we have a problem.

Find any well functioning unit in a hospital, and I will guarantee that it is a unit which encourages multi-disciplinary contribution in all of its work streams. Leadership will be strong, but it will not be overbearing - it will be inclusive, collaborative and occasionally deferential. Leadership is not about getting everyone to agree with you, it is about finding the best solutions, wherever they may come from, and implementing them. It is not about me, or you, it is about the process needed to achieve the goals we are aiming for.

And this is my point - I had to leave my training programme for a year to find out about leadership, because the leadership examples I was being exposed to didn’t strike me as being either effective or healthy.

We need to be more open about the development of leadership alongside clinical skills, and while this is partly addressed by the Medical Leadership Competencies Framework, there is still some way to go in addressing the language and culture of leadership in play. The Deaneries recognise the importance of developing leadership within junior doctors, but what they don’t perhaps realise it that it can be very difficult to find good role models within the workplace, and it is very difficult to find people who will guide you through your own personal development programme.

Addressing this issue is more than just telling people about it - there is a real need for junior doctors to become familiar with a gentler, less egocentric language of leadership. It is not about success or failure, it is about transparency and openness, and it involves adapting to the individual that you happen to be dealing with. If we start at the bottom with medical students and junior doctors, then I think we can generate a powerful, helpful and lasting change in culture that will result in doctors being leaders who can be valued and respected for their ability to lead, not just their ability to diagnose and treat.