Tag Archives: Doctors

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medical records to track the effect of removal of financial incentives on provider behaviour.[1] Incentives were withdrawn for 12 quality of care indicators in 2014, while they were retained for six indicators.

The results showed a sharp and almost immediate fall in adherence to the 12 indicators for which the incentive was withdrawn.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.
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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.

More on Medical School Admission

I thank Celia Taylor for drawing my attention to an important paper on the relationship between personality test results, and cognitive and non-cognitive outcomes at medical school.[1] Everyone accepts that being a good doctor is about much more than cognitive excellence. That isn’t the question. The question is how to select for salient non-cognitive attributes? The paper is a hard read because one must first learn the acronyms for all the explanatory and outcome tests. So let the News Blog take the strain!

The study uses a database containing entry level personality scores, which were not used in selection, and outcomes following medical training. To cut a long story short “none of the non-cognitive tests evaluated in this study has been shown to have sufficient utility to be used in medical student selection.” And, of course, even if a better test is found in the future, it may perform differently when used as part of a selection process than when used for scientific purposes. I stick by the conclusions that Celia and I published in the BMJ many years ago [2]; until a test is devised that predicts non-cognitive medical skills, and assuming that cognitive ability is not negatively associated with non-cognitive attributes, we should select purely on academic ability. I await your vituperative comments! In the meantime can I suggest a research idea – correlate cognitive performance with the desirable compassionate skills we would like to see in our doctor. Maybe the correlation is positive, such that the more intelligent the person, the more likely they are to demonstrate compassion and patience in their dealings with patients.

— Richard Lilford, CLAHRC WM Director

References:

  1. MacKenzie RK, Dowell J, Ayansina D, Cleland JA. Do personality traits assessed on medical school admission predict exit performance? A UK-wide longitudinal cohort study. Adv Health Sci Educ Theory Pract. 2017; 22(2): 365-85.
  2. Brown CA, & Lilford RJ. Selecting medical students. BMJ. 2008; 336: 786.

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.