Sunday, 19 June 2011

Is there anything you would like to ask me?

I remember being set an essay at school titled 'Scire – can we ever be said to know?' My memories of this essay are tinged with both guilt and pride, as I wilfully set out to not answer the question, choosing instead to blather on about the rise of empiricism, the death of philosophy and the intellectual redundancy of the arts to inform modern thinking. My guilt was driven by the knowledge that this was of course hogwash, while my pride was fuelled by the fact that the teacher who marked the essay rather liked my style of argument, and gave me an excellent mark.

When Neil MacGregor introduced 'A History of the World in 100 objects' he said, “Ever since man has been making objects, he has been making beautiful objects.” This statement has become the banner under which I guard against the kind of scientific arrogance I displayed when writing that essay, and which I see all around me both at work and in the world in general. In his book 'The Revenge of Gaia', James Lovelock, that stalwart of holistic science, bemoaned the super-specialisation of science, and argued that  individual experts now rarely see beyond his or her own narrow horizons. Breadth of knowledge is limited by the sheer volume of data that one must crunch in order to 'know' something. Scientific advances seem to balloon what needs to be remembered, rather that consolidate it; I always used to be comforted by the renaissance idea of the Uomo universale – a man pushing scientific artistic and scientific frontiers at the same time would seem to have all the intellectual checks and balances that he needs – almost as if in a world of ever increasing technological detail, empiricism provides the proof, while art and philosophy provide the sense.

I landed on these thoughts this weekend when Twitter comrade @mellojonny suggested that I could write about how doctors know whether their patients understand what they have told them. Ergo, 'Scire – can we ever be said to know?' I thought about the platitudinous waffle that both I and other doctors might be tempted to respond to this question with: 'My patients understand what I tell them because I use language they understand, and before the end of the consultation, I ask them to relate to me what they have been told.'

But it is much more complicated than that isn't it? Many of my patients think they understand what they have been told, and can repeat back a brief synospis of the information before I leave, but when I see them the next day, or after some weeks in clinic, it becomes apparent that this understanding was either illusory or temporary. Many of my patients, by virtue of dementia or delirium, never understand what they have been told. What, therefore, is a doctor to do?

In the context in which I treat patients, there are so many confounders to the key processes of helping the patient understand their medical problems and the treatment decisions that need to be made. Confusion abounds, both literally and metaphorically – where loss of cognitive faculties is not an issue, there is still the challenge of creating the calm and space in which patients can absorb information in the chaos of a medical ward, in the context of the emotional turbulence that admission to hospital precipitates. Friends and relatives are variously helpful – they usually mean well, but patients often worry more about how their relatives are coping than how than anything else.

The process of presenting information in a clear, concise way, and helping patients make decisions that are right for them is something I place a huge amount of importance on. But if I’m being really honest, in every conversation I have with patients, and every time I make recommendations to them, there is a great deal of me in there - my beliefs, feelings and values are with me all the time, and while I think I these serve me well, it is impossible that everyone I deal with will share them. For example, my views on religion shape my perception of how we should deal with death and dying very clearly, but patients and relatives with different religious views are bound to feel differently. I use this example for a particular purpose: religious views tend to be fixed and intransigent, especially in the short term, so the solution is not for me to persuade people I meet to agree with me - another approach is needed.

I realised that the patients who do ask me questions and challenge me are the ones with whom I have the type of interpersonal relationship that makes such conversations routine and comfortable. If a doctor asks a patient whether they have any questions, it is the doctor offering the patient the opportunity to speak - the doctor is still in charge. Where the doctor and the patient are two people working together for the benefit of the patient, the patient asking questions is simply a conversation.

There is no single formula that makes this shift in dynamic happen, but I find that I spend an increasing amount of my time explaining to patients what it is that I can do, and what it is that I can’t do. One of the conversational short cuts that I use is to tell the patients that I get paid to do the worrying, so that they can focus on the getting better. The emphasis is very much on the idea that I work for them, and my role is to manage the uncertainty, provide technical expertise, and to help them know what to expect. Acknowledging the bad stuff, admitting to problems and being prepared to be open and honest often creates the kind of trust that allows patients to ask me what I think is really troubling them.

The other key factor in helping patients understand is to ensure that the multi-disciplinary team is singing the same tune - this is not about backing each other up when we face criticism, but rather ensuring that we meet and talk often enough to know how everyone else is progressing with the patients. This does not take long, but it does require effort and dedicated time. Done well, this level of team-work ensures that every person who works with the patients re-enforces the same message and gives the same feedback and information to the patient. Therapists spend more time with the patients than I do, and patients often tell them their worries and concerns, and ask them questions that I thought I had given them the answers to. This can be a really useful source of feedback for me.

I don’t think that I am demystifying anything disastrously to admit that much of my job relies on chatting to patients and other professionals. Providing the space and time to talk at lesiure is an invaluable tool in knowing someone’s thoughts and feelings, and understanding usually reveals itself through the questions and actions of the patients I am working with. I don’t think think it’s possible always to know that a patient has understood what you have just told them, but where I work, there are some really good ways of finding out when they don’t.

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