Tag Archives: Communication

‘Information is not knowledge’: Communication of Scientific Evidence and how it can help us make the right decisions

Every one of us is required to make many decisions: from small decisions, such as what shoes to wear with an outfit or whether to have a second slice of cake; to larger decisions, such as whether to apply for a new job or what school to send our children to. For decisions where the outcome can have a large impact we don’t want to play a game of ‘blind man’s buff’ and make a decision at random. We do our utmost to ensure that whatever decision we arrive at, it is the right one. We go through a process of getting hold of information from a variety of sources we trust and processing that knowledge to help us make up our minds. And in this digital age, we have access to more information than ever before.

When it comes to our health, we are often invited to be involved in making shared decisions about our own care as patients. Because it’s our health that’s at stake, this can bring pressures of not only making a decision but also making the right decision. Arriving at a wrong decision can have significant consequences, such as over- or under-medication or missing out from advances in medicine. But how do we know how to make those decisions and where do we get our information from? Before we start taking a new course of medication, for example, how can we find out if the drugs are safe and effective, and how can we find out the risks as well as the benefits?

The Academy of Medical Sciences produced a report, ‘Enhancing the use of scientific evidence to judge the potential benefits and harms of medicine’,[1] which examines what changes would be necessary to help patients make better-informed decisions about taking medication. It is often the case that there is robust scientific evidence that can be useful in helping patients and clinicians make the right choices. However, this information can be difficult to find, hard to understand, and cast adrift in a sea of poor-quality or misleading information. With so much information available, some of it conflicting – is it any surprise that in a Medical Information Survey, almost two-thirds of British adults would trust experiences of friends and family compared to data from clinical trials, which only 37% of British adults would trust?[2]

The report offers recommendations on how scientific evidence can be made available to enable people to weigh up the pros and cons of new medications and arrive at a decision they are comfortable with. These recommendations include: using NHS Choices as a ‘go to’ hub of clear, up-to-date information about medications, with information about benefits and risks that is easy to understand; improving the design, layout and content of patient information leaflets; giving patients longer appointment times so they can have more detailed discussions about medications with their GP; and a traffic-light system to be used by the media to endorse the reliability of scientific evidence.

This is all good news for anyone having to decide whether to start taking a new drug. I would welcome the facility of going to a well-designed website with clear information about the risks and benefits of taking particular drugs rather than my current approach of asking friends and family (most of whom aren’t medically trained), searching online, and reading drug information leaflets that primarily present long lists of side-effects.

Surely this call for clear, accessible information about scientific evidence is just as relevant to all areas of medical research, including applied health. Patients and the public have a right to know how scientific evidence underpinning important decisions in care is generated and to be able to understand that information. Not only do patients and the public also make decisions about aspects of their care, such as whether to give birth at home or in hospital, or whether to take a day off work to attend a health check, but they should also be able to find and understand evidence that explains why care is delivered in a particular way, such as why many GPs now use a telephone triage system before booking in-person appointments. Researchers, clinicians, patients and communicators of research all have a part to play.

In CLAHRC West Midlands, we’re trying to ‘do our bit’. We aim to make accessible a sound body of scientific knowledge through different information channels and our efforts include:

  • Involving patients and the public to write lay summaries of our research projects on our website so people can find out about the research we do.
  • Communication of research evidence in accessible formats, such as CLAHRC BITEs, which are reviewed by our Public Advisors.
  • Method Matters, a series aimed to give members of the public a better understanding of concepts in Applied Health Research.

The recommendations from the Academy of Medical Sciences can provide a useful starting point for further discussions on how we can communicate effectively in applied health research and ensure that scientific evidence, rather than media hype or incomplete or incorrect information, is the basis for decision-making.

— Magdalena Skrybant, CLAHRC WM PPIE Lead

References:

  1. The Academy of Medical Sciences. Enhancing the use of scientific evidence to judge the potential benefits and harms of medicine. London: Academy of Medical Sciences; 2017.
  2. The Academy of Medical Sciences. Academy of Medical Sciences: Medical Information Survey. London: Academy of Medical Sciences; 2016

Doctor-Patient Communication in the NHS

Andrew McDonald (former Chief Executive of Independent Parliamentary Standards Authority) was recently asked by the Marie Curie charity to examine the quality of doctor-patient communication in the NHS, as discussed on BBC Radio 4’s Today programme on 13 March 2017 (you can listen online). His report concluded that communication was woefully inadequate and that patients were not getting the clear and thorough counselling that they needed in order to understand their condition and make informed choices about options in their care. Patients need to understand what is likely to happen to them, and not all patients with the same condition will want to make the same choice(s). Indeed my own work [1] is part of a large body of research, which shows that better information leads to better knowledge, which in turn affects the choices that patients make. Evidence that the medical and caring professions do not communicate in an informative and compassionate way is therefore a matter of great concern.

However, there is a paradox – feedback from patients, that communication should lie at the heart of their care, has not gone unheard. For instance, current medical training is replete with “communication skills” instruction. Why then do patients still feel dissatisfied; why have matters not improved radically? My diagnosis is that good communication is not mainly a technical matter. Contrary to what many people think, the essence of good communication does not lie in avoiding jargon or following a set of techniques – a point often emphasised by my University of Birmingham colleague John Skelton. These technical matters should not be ignored – but they are not the nub of the problem.

In my view good communication requires effort, and poor communication reflects an unwillingness to make that effort; it is mostly a question of attitude. Good communication is like good teaching. A good communicator has to take time to listen and to tailor their responses to the needs of the individual patient. These needs may be expressed verbally or non-verbally, but either way a good communicator needs to be alive to them, and to respond in the appropriate way. Sometimes this will involve rephrasing an explanation, but in other cases the good communicator will respond to emotional cues. For example a sensitive doctor will notice if, in the course of a technical explanation, a patient looks upset – the good doctor will not ignore this cue, but will acknowledge the emotion, invite the patient to discuss his or her feelings, and be ready to deal with the flood of emotion that may result. The good doctor has to do emotional work, for example showing sympathy, not just in what is said, but also in how it is said. I am afraid to say that sometimes the busyness of the doctor is simply used as an excuse to avoid interactive engagements at a deeper emotional level. Yes, bringing feelings to the surface can be uncomfortable, but enduring the discomfort is part of professional life. In fact, recent research carried out by Gill Combes in CLAHRC WM showed that doctors are reticent in bringing psychological issues into the open.[2] Deliberately ignoring emotional clues and keeping things at a superficial level is deeply unsatisfying to patients. Glossing over feelings also impedes communication regarding more technical issues, as it is very hard for a person to assimilate medical information when they are feeling emotional, or nursing bruised feelings. In the long run such a technical approach to communication impoverishes a doctors professional life.

Doctors sometimes say that they should stick to the technical and that the often lengthy business of counselling should be carried out by other health professions, such as nurses. I have argued before that this is a blatant and unforgivable abrogation of responsibility; it vitiates values that lie (and always will lie) at the heart of good medical practice.[3] The huge responsibilities that doctors carry to make the right diagnosis and prescribe the correct treatment entail a psychological intimacy, which is almost unique to medical practice and which cannot easily be delegated. The purchase that a doctor has on a patient’s psyche should not be squandered. It is a kind of power, and like all power it may be wasted, misused or used to excellent effect.

The concept I have tried to explicate is that good communication is a function of ethical practice, professional behaviour and the medical ethos. It lies at the heart of the craft of medicine. If this point is accepted, it has an important corollary – the onus for teaching communication skills lies with medical practitioners rather than with psychologists or educationalists. Doctors must be the role models for other doctors. I was fortunate in my medical school in Johannesburg to be taught by professors of Oslerian ability who inspired me in the art of practice and the synthesis of technical skill and human compassion. Some people have a particular gift for communication with patients, but the rest of us must learn and copy, be honest with ourselves when we have fallen short, and always try to do better. The most important thing a medical school must do is to nourish and reinforce the attitudes that brought the students into medicine in the first place.

— Richard Lilford, CLAHRC WM Director

References:

  1. Wragg JA, Robinson EJ, Lilford RJ. Information presentation and decisions to enter clinical trials: a hypothetical trial of hormone replacement therapy. Soc Sci Med. 2000; 51(3): 453-62.
  2. Combes G, Allen K, Sein K, Girling A, Lilford R. Taking hospital treatments home: a mixed methods case study looking at the barriers and success factors for home dialysis treatment and the influence of a target on uptake rates. Implement Sci. 2015; 10: 148.
  3. Lilford RJ. Two Ideas of What It Is to be a Doctor. NIHR CLAHRC West Midlands News Blog. August 14, 2015.

Scientists Should Not Be Held Accountable For Ensuring the Impact of Their Research

It has become more and more de rigour to expect researchers to be the disseminators of their own work. Every grant application requires the applicant to fill in a section on dissemination. We were recently asked to describe our dissemination plans as part of the editorial review process for a paper submitted to the BMJ. Only tact stopped us from responding, “To publish our paper in the BMJ”! Certainly when I started out on my scientific career it was generally accepted that the sciences should make discoveries and journals should disseminate them. The current fashion for asking researchers to take responsibility for dissemination of their work emanates, at least in part, from the empirical finding that journal articles by themselves may fail to change practice even when the evidence is strong. Furthermore, it could be argued that researchers are ideal conduits for dissemination. They have a vested interest in uptake of their findings, an intimate understanding of the research topic, and are in touch with networks of relevant practitioners. However, there are dangers in a policy where the producers of knowledge are also held accountable for its dissemination. I can think of three arguments against policies making scientists the vehicle for dissemination and uptake of their own results – scientists may not be good at it; they may be conflicted; and the idea is based on a fallacious understanding of the normative and practical link between research and action.

1. Talent for Communication
There is no good reason to think that researchers are naturally gifted in dissemination, or that this is where their inclination lies. Editors, journalists, and I suppose blog writers, clearly have such an interest. However, an inclination to communicate is not a necessary condition for becoming an excellent researcher. Specialisation is the basis for economic progress, and there is an argument that the benefits of specialisation apply to the production and communication of knowledge.

2. Objectivity
Pressurising researchers to market their own work may create perverse incentives. Researchers may be tempted to overstate their findings, or over interpret the implications for practice. There is also a fine line to be drawn between dissemination (drawing attention to findings) and advocacy (persuading people to take action based on findings). It is along the slippery slope between dissemination and advocacy that the dangers of auto-dissemination reside. The vested interest that scientists have in the uptake of their results should serve as a word of caution for those who militantly maintain that scientists should be the main promotors of their own work. The climate change scientific fraternity has been stigmatised by overzealous scientific advocacy. Expecting scientists to be the bandleader for their own product, and requiring them to demonstrate impact, has created perverse incentives.

3. Research Findings and Research Implications
With some noble exceptions, it is rare for a single piece of primary research to be sufficiently powerful to drive a change in practice. In fact replication is one of the core tenets of scientific practice. The pathway from research to change of practice should go as follows:

  1. Primary researcher conducts study and publishes results.
  2. Research results replicated.
  3. Secondary researcher conducts systematic review.
  4. Stakeholder committee develops guidelines according to established principles.
  5. Local service providers remove barriers to change in practice.
  6. Clinicians adapt a new method.

The ‘actors’ at these different stages can surely overlap, but this process nevertheless provides a necessary degree of detachment between scientific results and the actions that should follow, and it makes use of different specialisms and perspectives in translating knowledge into practice.

We would be interested to hear contrary views, but be careful to note that I am not arguing that a scientist should never be involved in dissemination of their own work, merely that this should not be a requirement or expectation.

— Richard Lilford, CLAHRC WM Director

What is a GP for? – The End of the Fixed Consultation Period?

General Practitioners throughout the UK provide ten-minute consultation slots by default. An increasing portion of patients are seen for chronic disease and increasingly routine consultation are carried out by practice nurses. Telephone consultations are routine in many practices. The idea is that the GP should see the more complex cases. In theory this skill substitution should liberate time allowing GPs to provide larger default slots to patients. However, this has not happened, likely because demand has increased. Given that a further expansion in the GP cadre is not going to happen any time soon, should this state of affairs be accepted? It seems to me that the status quo cannot be endured – at least not without concerted effort to change it.

Consider first the patient. Can the needs of the patient really be met in such a short consultation unless they are very straightforward? And if they are straightforward, then is a highly trained and expensive professional needed? Dealing with depression, managing refractory blood pressure in a diabetic patient who is also complaining of a sore foot, counselling a patient who is considering whether or not to have a third round of chemotherapy – these are not ten minute tasks, but they are the stuff of primary care.

If you cannot provide compassionate care in five minutes, then how can you make a diagnosis? You need to record the symptoms, ask the patient to undress, elicit signs, and think about what it all means. Twenty-two percent of cancers present as emergencies,[1] and many of these patients have been seen by GPs before presentation.[2]

And what about the provider? I am consumer-orientated by philosophy, but at some point the provider interest becomes the consumer interest. Imagine consulting all day long, five days a week, for 45 years, at six patients per hour! Contrast that with an “old-fashioned” doctor; deliver a baby, consult in rooms, set a fracture, few more consultations, home visits.

Back in the 1950s the great Michael Balint spotted the problem. He advocated fewer consultations in greater detail for non-psychotic mental illness.[3] [4] So the idea is not new, and the challenge now is to find a way to make best use of advanced medical skills. Lots of things that seemed inviolate have been changed by human agency – the closing of the great mental asylums to be replaced by community care, for example. So let’s model how the service could look based on real patient lists. Then let’s simulate different methods to change the pattern of care, invoking plentiful skill substitution and perhaps greater reliance on technology and self-help. Then we could pilot it and finally roll it out, seeking buy-in from professional bodies. In fact, reverse that – let the professional bodies make the running while researchers in organisations such as CLAHRCs provide scientific ballast.

— Richard Lilford, CLAHRC WM Director

Reference:

  1. National Cancer Intelligence Network. Routes to Diagnosis 2006-13. 2015.
  2. Kidney E, Berkman L, Macherianakis A, et al. Preliminary results of a feasibility study of the use of information technology for identification of suspected colorectal cancer in primary care: the CREDIBLE study. Br J Cancer. 2015; 112(s1): s70-6.
  3. Balint M. The Doctor, his Patient, and the Illness. Lancet. 1955; 265(6866): 683-8.
  4. Balint M. The Doctor, his Patient, and the Illness. 2nd Edinburgh: Churchill Livingstone, 2000.

Getting Evidence into Practice

In the early days of CLAHRCs, ‘getting evidence into practice‘ was an important objective. We set about closing the T2 gap and used implementation science to get doctors to prescribe evidence-based care, dentists to use tooth protecting resins, and nurses to make regular observations. That is to say, we were concerned with how to make practitioners comply with standards over which they had complete jurisdiction. Theories of individual behaviour change were invoked, and rather then choose a theory on the basis of its impressive sounding title (e.g. prospect theory, social network theory), a framework was developed to identify barriers and facilitators of change.[1]

But practitioners increasingly follow the evidence when it is compelling and when the evidence-based standard is in their gift.[2] So, the big (and much more interesting) problem now is how to change the service in a generic way rather than simply to increase performance on a specific measure – we are becoming more concerned with draining the swamp than zapping individual mosquitoes.[3] In our CLAHRC we recently evaluated a compound (multi-component) intervention to improve home dialysis rates, having promulgated a guideline supporting improved access to such a service. We showed that agreement with the proposed change among stakeholders, an agreed

Implementation plan, managerial support, and product champions all facilitated the success of the intervention in taking West Midlands from the worst to the best performing region in England. However, the king of all intervention components was a financial incentive.[4] Fulop and colleagues have now published a similar multi-methods evaluation of an arguably even more complex intervention to improve access to acute stroke care.[5] The findings are very similar, save that we found more emphasis on financial incentives and also more problems in communication with patients; something that would perhaps not stand out in the hyper acute stroke context. The Fulop paper is an advance on ours in (at least) two respects. First, they compare and contrast across two regions/CLAHRCs and I always think controls should be used if possible; even one is better than none. Second, they illustrate the causal model with diagrams that make the theoretical framework they are using clear, a practice that is helpful in communicating the very real distinctions between the intervention as planned, its implementation/adaption, its upstream effects (e.g. staff knowledge/morale), its downstream effects (at the patient ‘level’), and the context in which all takes place.[6] People muddle these concepts and hence fall over their feet , but Fulop and colleagues have shown themselves to be sure-footed!

— Richard Lilford,

References:

  1. Michie S, van Stralen M, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventionsImplement Sci. 2011; 6: 42.
  2. Johnson N, Sutton J, Thornton JG, Lilford RJ, Johnson VA, Peel KR. Decision analysis for best management of mildly dyskaryotic smear. Lancet. 1993;342(8863):91-6
  3. Lilford RJ, Chilton PJ, Hemming K, Girling AJ, Taylor CA, Barach P. Evaluating policy and service interventions: framework to guide selection and interpretation of study end pointsBMJ. 2010; 341: c4413.
  4. Combes G, Allen K, Sein K, Girling A, Lilford R. Taking hospital treatments home: a mixed methods case study looking at the barriers and success factors for home dialysis treatment and the influence of a target on uptake ratesImplement Sci. 2015; 10: 148.
  5. Fulop NJ, Ramsay AIG, Perry C, et al. Explaining outcomes in major system change: a qualitative study of implementing centralised acute stroke services in two large metropolitan regions in England. Implement Sci. 2016; 11: 80.
  6. Lilford RJ, Chilton PJ, Hemming K, Girling AJ, Taylor CA, Barach P. Evaluating policy and service interventions: framework to guide selection and interpretation of study end points. BMJ. 2010; 341: c4413.

Assessing Patient-Centred Care Through Direct Observation of Clinical Encounters

Ironically the most private and sensitive part of medical care is also one of the most accessible to measurement – yes doctor-patient psychological interaction (communication is too shallow a word) can be observed directly and does not suffer from poor signal to noise ratios since it differs so much between doctors and across contexts. It can be calibrated on a continuous or ordinal scale, and thus tends to be measured with high precision. The CLAHRC WM Director does not know how reliable it is, but it is undoubtedly hugely important. Stojan and colleagues [1] write a very nice paper about this subject and remind us of the chilling finding that doctors tend to adopt a different style for different ethnic groups. It is important that we have this mirror in place. There is no asymptote to improved interaction with patients, and we should feel good about ourselves because we have faced up to our imperfections and are trying to improve, rather than bad because we are not perfect in this – by far the most difficult – aspect of professional practice.

— Richard Lilford, CLAHRC WM Director

Reference:

  1. Stojan JN, Clay MA, Lypson ML. Assessing patient-centred care through direct observation of clinical encounters. BMJ Qual Saf. 2016; 25: 135-7.