Tag Archives: Doctors

Case Study of Physician Associates

Health care is becoming increasingly complex as a result of the developments in therapy and changing demography. Health care is a massive service industry and one of the largest parts of the economy in high-income countries. Like most service industries, health care relies heavily on human resources, and costs can be controlled by skill substitution from more expensive people making judgements under uncertainty to less expensive people operating in a more algorithmic way. So it is interesting to read an account of physician associates recently published in the BMJ Open.[1] The UK will soon graduate over 3,000 physician associates per year – about a third as many as the number of doctors. So it is good to learn from this paper that they are well accepted in hospital practice by staff and patients alike, and appear to function effectively. In other countries they may prescribe medicines and x-rays with prohibition. The UK should follow suit with respect to medicines that are widely used and have high therapeutic indices. I also think physician associates may have a larger role in primary care in the future.

— Richard Lilford, CLAHRC WM Director

Reference:

  1. Drennan VM, Halter M, Wheeler C, et al. What is the contribution of physician associates in hospital care in England? A mixed methods, multiple case study. BMJ Open. 2019; 9: e027012.
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Do Poor Examination Results Predict That a Doctor Will Get into Trouble with the Regulator?

A recent paper by Richard Wakeford and colleagues [1] reports that better performance in postgraduate examinations for membership of the Royal Colleges of General Practitioners and of Physicians (MRCGP and MRCP respectively) is associated with a reduced likelihood of being sanctioned by the General Medical Council for insufficient fitness to practise. The effect was stronger for examinations of clinical skills, as opposed to those of applied medical knowledge, but was statistically significant for all five examinations studied. The unweighted mean effect size (Cohen’s d) was -0.68 – i.e. doctors with sanctions had examination scores that were, on average, around two-thirds of a standard deviation below those of doctors without a sanction. The authors find a linear relationship between performance and the likelihood of a sanction, which suggests that there was no clear performance threshold at which there is a significant change in the risk of a sanction.

The main analysis does not control for the timing of the examination attempt vis-á-vis the timing of the sanction, and the authors rightly point out that having a sanction could reduce subsequent examination performance due to the stress of being under investigation, for example. However the results of a sub-analysis for two of the knowledge assessments (MRCGP Applied Knowledge Test, and MRCP Part 1) suggest a slightly larger effect size when only considering doctors whose examination attempt was at least two years before their sanction, so the “temporality” requirement for causation is not absent. We also know there is some stability in relative examination performance (and, plausibly, therefore, knowledge) over time [2] – so “reversed” timing may not be a critical bias.

This study is important as it suggests that performance on the proposed UK Medical Licensing Assessment (UKMLA) (which is likely to be similar in format to both the examinations included in this study) may be a predictor of future standards of professional practice. However, the study also suggests that it may not be possible to find a pass mark for the UKMLA that has a significant impact on the number of doctors for whom sanctions are imposed (in comparison to other possible pass marks). Given the intention of the UKMLA as a pass/fail assessment and the low rate of sanctions amongst doctors on the GMC register (1.6% of those on the register in January 2017 had one or more sanctions since September 2008, and even lower amongst doctors in their first decade since joining the register), it is unlikely that the introduction of the UKLMA will have a detectable difference on the rate of sanctions. As a result, other outcome measures for an evaluation of its predictive validity will be needed, even with a large sample size (around 8,000 UK candidates per year).

Nevertheless, given that at least some sanctions relate to communication (and not just clinical performance), the results of Wakeford and colleagues’ study also imply that there is not necessarily a trade-off between a doctor’s knowledge base and their skills relating to communication, empathy and bedside manner. This may have implications for those responsible for selection into and within the profession, as Richard Lilford and I suggested some time ago.[3] Taken to its limit, it could be argued that the expensive and often criticised situational judgement test which is intended to evaluate the non-cognitive attributes of doctors may not be required after all.

— Celia Brown, Associate Professor

References:

  1. Wakeford R, Ludka K, Woolf K, McManus IC. Fitness to practise sanctions in UK doctors are predicted by poor performance at MRCGP and MRCP(UK) assessments: data linkage study. BMC Medicine. 2018; 16: 230.
  2. McManus IC,Woolf K, Dacre J, Paice E, Dewberry C. The Academic Backbone: longitudinal continuities in educational achievement from secondary school and medical school to MRCP(UK) and the specialist register in UK medical students and doctorsBMC Medicine. 2013: 11:242.
  3. Brown CA, & Lilford RJ. Selecting medical students. BMJ. 2008; 336: 786.

Quality of Care on Removal of Financial Incentives in General Practices

Minchin, et al. report on the use of interrupted time series analyses of electronic medical records to track the effect of removal of financial incentives on provider behaviour.[1] Incentives were withdrawn for 12 quality of care indicators in 2014, while they were retained for six indicators.

The results showed a sharp and almost immediate fall in adherence to the 12 indicators for which the incentive was withdrawn. There was no such drop in performance for the six indicators that were retained.

Many of the measurements of adherence were based on clinician entry into the electronics records to confirm compliance. For example, to confirm that advice on disease prevention had been given. It is therefore possible that clinicians continued to adhere to the tenets of good practice after withdrawal of the incentive, while simply omitting to record this detail in the electronic notes. However, not all measurements were dependent on active clinical entry – for example, the electronic record is populated automatically with blood test results. There was a fall in adherence to previously incentivised indicators, such as blood tests, where physician entry was bypassed, as well as on those that required physician entry. However, the fall in compliance with practice standards that did not depend on physician entry was not as great as the fall in compliance with indicators that depend on physician entry.

The results reported here are broadly in-line with the literature; removal of financial incentives for clinical care standards is generally followed by a decline in performance.

What does this mean for the use of performance measures? One must assume that they cannot be retained in perpetuity; at some point the world must move on, even if only to implement a further set of performance measures.  But my overarching impression is reconfirmed – the use of incentives, measurements and targets is of limited value. In the last analysis, the only way to bring about a sustained, lasting and self-perpetuating improvement in care, is by winning the hearts and minds of clinicians. It is important to kindle a set of high rectitude values, and it is important to select individuals with the right characteristics, i.e. highly principled people with a deep sense of altruism. This is, I am afraid, an ultra-long-term solution – a person’s attitude starts on mother’s knee and is reinforced or supressed by the totality of life experience. Inspiring teachers at medical school and good role models throughout life are critical. That is one reason that I continue to argue that medical ethics and, so-called, ‘communication skills’ should be taught by doctors and not farmed out to philosophers and psychologists.[2] When I was a clinical professor these valuable colleagues taught me, but I taught the students.

— Richard Lilford, CLAHRC WM Director

References:

  1. Minchin M, Roland M, Richardson J, Rowark S, Guthrie B. Quality of Care in the United Kingdom after Removal of Financial Incentives. N Engl J Med. 2018; 379: 948-57.
  2. Lilford RJ. Doctor-Patient Communication in the NHS. NIHR CLAHRC West Midlands News Blog. 24 March 2017.

Does Having an Empathetic Doctor Improve Clinical Outcomes?

Expressions of empathy by a doctor can improve patient satisfaction.[1] And there is evidence that expression of empathy can be taught.[2] But does consultation with an empathetic doctor result in better symptom control than consultation with a doctor who is not as empathetic? A recent review of the topic found seven RCTs addressing this point.[3] The outcomes were measured on a continuous scale so they could be combined through their standardised mean difference in a meta-analysis. All point estimates were favourable and there was a statistically significant effect across all seven included studies. The difference of 0.42 of a standard deviate for pain was described as ‘moderate’, but sounds impressive to me. The study also included trials of ‘positive communication’ designed to engender good expectations of treatment effect. Again, modest effects were noted, but I am cautious about such an approach as it may topple over into dishonesty. Empathy is a different matter and this paper provides yet more evidence on how important it is. Doctors need to display warmth, consideration and appropriate affect – they have to make an effort and do ‘emotional work’. Building a relationship with patients is the essence of practice. Making the diagnosis and performing procedures is the easy bit for experienced doctors. But there is no ceiling to excellence in patient communication.

— Richard Lilford, CLAHRC WM Director

References:

  1. Kim SS, Kaplowitz S, Johnston MV. The Effects of Physician Empathy on Patient Satisfaction and Compliance. Eval Health Prof. 2004; 27(3): 237-51.
  2. Lilford RJ. Is it Possible to Teach Empathy? NIHR CLAHRC West Midlands News Blog. 10 November 2017.
  3. Howick J, Moscrop A, Mebius A, et al. Effects of empathic and positive communication in healthcare consultations: a systematic review and meta-analysis. J Roy Soc Med. 2018.

More on why AI Cannot Displace Your Doctor Anytime Soon

News blog readers will be familiar with my profound scepticism about the role of artificial intelligence (AI) in medicine.[1] I have consistently made the point that there is no clear outcome to much medical process. This is quite different to a game of Go where, in the end, you either win or lose. Moreover, AI can simply replicate human error by replicating faulty parts of human processes. I previously used the example of racial bias in police work as an example.[2] Also, when you take a history, then the questions you ask are informed by medical logic or intuition. And eliciting the correct answer is partly a matter of good empathetic approach, as pointed out beautifully in a recent article by Alastair Denniston and colleagues.[3] So comparing AI with a physician is really comparing a physician with physician plus AI.

A further important article on the limitations of AI that has recently come out in the journal Science.[4] The article explains how AI can outperform human operators on a game of Space Invaders; but if the game is suddenly altered until all but one alien is removed, the AI performance deteriorates. A human player can immediately spot the problem, whereas the AI system is flummoxed for many iterations. The article explains how AI is coming full circle. First, computer scientists tried to mimic expert performance at a task. Then, AI completely bypassed the expert by means of a self-learning neural network. They declared victory when ‘AlphaGo’ beat Go champion Ke Jie. That was the high water mark for AI, and although a few enthusiasts declared victory,[5] serious AI scientists have turned back to human intelligence to inform their algorithms. They are even starting to study how children learn and using this knowledge in AI systems.

— Richard Lilford, CLAHRC WM Director

References:

  1. Lilford RJ. Update on AI. NIHR CLAHRC West Midlands News Blog. 1 June 2018.
  2. Lilford RJ. How Accurate Are Computer Algorithms Really? NIHR CLAHRC West Midlands News Blog. 26 January 2018.
  3. Liu X, Keane PA, Denniston AK. Time to regenerate: the doctor in the age of artificial intelligence. J Roy Soc Med. 2018; 111(4): 113-6.
  4. Hutson M. How researchers are teaching AI to learn like a child. Science. 24 May 2018.
  5. Lilford RJ. Computer Beats Champion Player at Go – What Does This Mean for Medical Diagnosis? NIHR CLAHRC West Midlands News Blog. 8 April 2016.

Medically Unexplained Symptoms – Nocebo Effects Provide a Non-Pejorative Way to Explain Them

My hero – Michael Balint – was aware of the power of words in his classic ‘The Doctor, his Patient and the Illness.’[1] [2] He discusses patients with medically unexplained symptoms. This constellation is the subject of a study in which CLAHRC WM and the WM-AHSN are collaborating.

One tricky issue concerns getting patients off the diagnostic treadmill without annoying them by implying that the symptoms originate in their mind. When I was in practice I used to say that medically unexplained does not mean the symptoms are not real – I suffered headaches and they were real enough, for all that I did not have any specific disease. Now, writing in JAMA, Arthur Barsky makes a further helpful suggestion.[3] He advises clinicians to tell patients about the nocebo effect. Tell patients that their beta-blocker might cause erectile dysfunction, for example, and you will cause more erectile dysfunction than if the topic is not mentioned – 32% if they are warned instead of 13% if they are not.[4] Likewise, patients who have lower back pain and are randomised to receive MRI suffer more pain, more visits and more disability than those randomised to no imaging. The author argues that explaining that the mind is quite capable of amplifying symptoms will help patients understand that symptoms can be amplified as a result of anxiety and that more testing is likely to make matters worse.

The findings do create something of a dilemma for patients and their doctors with respect to information disclosure when people are offered a chance to participate in trials. On the one hand, it is unethical not to tell patients about potential side effects, while on the other the probability of those very side-effects is increased by disclosing that they may occur. The author suggests an interesting way out – he suggests that the clinician should seek permission not to disclose the details of symptoms that are known to be labile and that do not threaten life and limb.

The deeper message from this paper is the focus on the importance of words in clinical consultations. They really do matter, but there can be a clash between words that please and words that are honest.[5]

 — Richard Lilford, CLAHRC WM Director

References:

  1. Balint M. The Doctor, his Patient, and the IllnessLancet. 1955; 265(6866): 683-8.
  2. Balint M. The Doctor, his Patient, and the Illness. 2nd Edinburgh: Churchill Livingstone, 2000.
  3. Barsky AJ. The Iatrogenic Potential of the Physician’s Words. JAMA. 2017; 318(24): 2425-6.
  4. Cocco G. Erectile dysfunction after therapy with metoprolol: the Hawthorne effect. Cardiology. 2009; 112(3): 174-7.
  5. Lilford RJ. Ethics of clinical trials from a Bayesian and decision analytic perspective: whose equipoise is it anyway? BMJ. 2003; 326: 980-1.

How to Go About Non-Directive Consulting

I used to spend a lot of time talking to couples about their choices in reproductive medicine – whether to have prenatal testing or have a termination of pregnancy, for example. I learned from a psychotherapist with whom I worked, Susie Godsil, the importance of not just launching in with the facts, but first giving people a chance to express their feelings and establish a relationship. Only then would I start describing the alternatives and associated probabilities of outcomes. I was prepared to blend my approach to the particular couple. So I was interested to read a multi-stage framework for decision-making in the BMJ.[1] In my opinion it is a mistake to over-elaborate the process and apply a sequential approach. Consultation is partly tacit and, like good education, it should be reactive to the particular person you are consulting. The general principle holds – supporting patients’ decisions is neither a translational exchange of laying out the probabilities, nor a purely empathetic exploration of feelings, but a subtle blend of both. Shoehorning this nuanced approach into a flow diagram seems like overly codifying human interchange. I suppose this controversy could be put to an empirical test, but I would not participate in such a trial as I am not in equipoise.[2]

— Richard Lilford, CLAHRC WM Director

References:

  1. Elwyn G, Durand MA, Song J, Aarts J, Barr PJ, Berger Z, et al. A three-talk model for shared decision making: multistage consultation process. BMJ. 2017; 359: j4891.
  2. Lilford RJ & Jackson J. Equipoise and the Ethics of Randomization. J R Soc Med. 1995; 88(10): 552-9.

“We seek him here, we seek him there, Those Frenchies seek him everywhere.”

The notorious weekend mortality effect is every bit as elusive as the Scarlet Pimpernel. Recent studies have delved deeper into the possibility that the weekend effect is an artefact of admission of sicker patients at the weekend than on week days.[1] First, it has been shown that the mortality of all who present to the emergency department (i.e. admitted plus sent home) is the same over the weekend as over the rest of the week.[2] Second, patients who arrive by ambulance are generally much sicker than patients arriving by other means and the proportion who arrive by ambulance is higher over the weekend than over weekdays.[3] When controlling for method of arrival, most of the weekend effect disappears. Most, but not all. This paper provides further evidence that most estimates of the weekend effect are at least overestimates. Through Professor Julian Bion’s HiSLAC Study [4] we are evaluating the effect of weekend admission, not just on mortality, but also on the quality of care and the overall adverse event rate. We will use a Bayesian network to synthesise information across the causal chain and come up with a refined estimate of the effect of weekend admission, not only on mortality, but also on other adverse events.

— Richard Lilford, CLAHRC WM Director

References:

  1. Bray BD, Steventon A. What have we learnt after 15 years of research into the ‘weekend effect’? BMJ Qual Saf. 2017; 26: 607-10.
  2. Aldridge C, Bion J, Boyal A, et al. Weekend specialist intensity and admission mortality in acute hospital trusts in England: a cross-sectional study. Lancet. 2016. 388: 178-86.
  3. Anselmi L, Meacock R, Kristensen SR, Doran T, Sutton M. Arrival by ambulance explains variation in mortality by time of admission: retrospective study of admissions to hospital following emergency department attendance in England. BMJ Qual Saf. 2017; 26: 613-21.
  4. Chen Y, Boyal A, Sutton E, et al. The magnitude and mechanisms of the weekend effect in hospital admissions: A protocol for a mixed methods review incorporating a systematic review and framework synthesis. Syst Rev. 2016; 5: 84.

Numbers and the Doctor/Patient Relationship

I have always been interested in communicating scientific information and probability. A paper co-authored by CLAHRC WM colleague Eivor Oborn [1] therefore caught my eye. The paper concerns numbers and their ‘performativity’, by which the authors mean how the numbers affect doctors, patients, and the interaction between doctors and patients. They use medical consultations in a Swedish rheumatology clinic to explore the issue, since this is a ‘data-rich’ environment. By this I mean charts are used to plot long-run numerical data relating to patient-reported outcomes, medical assessments, and laboratory data. The study shows that the numbers have high salience for patients who generally find graphical representation of long-run data useful. Doctors also find graphical display of trends useful in spotting threats to patient health. However, patients sometimes feel that the data on display take precedence over how they actually feel. That is to say, the doctor tends to focus on the numbers while the patient’s main symptom might not be captured in the numbers. Of course, there is no counterfactual, so how much of this dissatisfaction is caused by availability of numbers is uncertain. Also I felt that more could be said about the extent to which patients, and indeed doctors, really understand the meaning of the numbers they were seeing. Many people have poor numeracy skills and draw erroneous inferences from data. For instance, people tend to over-interpret improving trends following a run of high-values – the issue of regression to the mean, covered in the Method Matters section of a previous News Blog.

— Richard Lilford, CLAHRC WM Director

Reference:

  1. Essén A & Oborn E. The performativity of numbers in illness management: The case of Swedish Rheumatology. Soc Sci Med. 2017; 184: 134-43.

Providing Care at Less Cost – the Great Skill-mix Debate

Health care professionals do not all receive the same emoluments. In all countries doctors are paid the most. They carry the greatest responsibility for making decisions that affect people and they are the most likely to be sued – so their differential pay seems fair. But the other side of the coin is that non-doctor health professionals can do many things equally well, or perhaps better. Similarly, there are things that Community Health Workers can do as well or better than nurses, and again at lower unit cost. There are many types of skill mix initiative, and the most widely used classification emanated from Bonnie Sibbald,[1] herself a previous CLAHRC director:

Sibbald’s Skill-Mix Classification

Changing roles

  • Extending roles
  • Substituting – exchanging one type of worker for another
  • Delegation
  • Innovation – creating new jobs

Changing structures at the interface between services

  • Transferring service from one setting to another
  • Relocation
  • Liaison

There are a number of systematic reviews on skill-mix summarising a great many articles. However, review authors agree that there is little clear evidence on effectiveness or cost-effectiveness. Many studies concentrate on skill substitution, usually comparing doctors and nurses.[2] However, the subject is hard to study, and deriving generalisable conclusions is always going to be difficult because of differences in context – especially training. One cadre that has received a lot of attention over the last two decades involves innovation more than substitution – the use of Community Health Workers. They have a valuable role in prevention (e.g. malnutrition/vaccination), maintenance of therapy (e.g. HIV, TB and hypertension), and frontline care (e.g. rehydration therapy), as discussed in previous News Blogs.[3-5]

— Richard Lilford, CLAHRC WM Director

References:

  1. Sibbald B, Shen J, McBride A. Changing the skill-mix of the health care workforce. J Health Serv Res Policy. 2004; 9(s1):28-38.
  2. Antunes V & Moreira JP. Skill mix in healthcare: An international update for the management debate. Int J Healthc Man. 2013; 6(1): 12-7.
  3. Lilford RJ. Lay Community Health Workers. NIHR CLAHRC West Midlands News Blog. 10 April 2015.
  4. Lilford RJ. An Intervention so Big You Can See it from Space. NIHR CLAHRC West Midlands News Blog. 4 December 2015.
  5. Lilford RJ. Between Policy and Practice – the Importance of Health Service Research in Low- and Middle-Income Countries. NIHR CLAHRC West Midlands News Blog. 27 January 2017.