Tag Archives: Doctors

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.

Are Female Doctors Better Than Male Doctors?

There seems to be two models of feminism:

  1. Women and men are constitutionally identical (in everything but size and appearance), and any observed differences are entirely patterned by social influences.
  2. Differences between men and women are more than just anatomy and physiology, and women bring useful and unique attributes to society.

I am inclined to the second opinion. It is already known that female doctors are more likely to adhere to clinical guidelines, provide more preventative advice, and are better listeners than male doctors. Well they also seem to save more lives, according to a brilliant study from Yasuke Tsugawa and colleagues.[1] They compared outcomes from Medicare beneficiaries treated by general internists in hospital. These were really sick patients with a death rate of over 11%. The patients treated by female doctors had a risk-adjusted difference in mortality of nearly 0.5% and also lower risk of readmission. Findings were similar if the analysis was restricted to patients treated by ‘hospitalists’ – a general physician on call for emergencies. Patients hospitalised for an emergency medical condition are less likely to select their physician than patients who are admitted electively, and severity and condition profiles were well balanced between male and female physicians. The authors claim that this means their study was ‘quasi-randomised’. The results are congruent with other studies; across many industries it has been shown that men, compared to women, are “less deliberate in their approach to solving complex problems.”

In ‘My Fair Lady’ Henry Higgins sings “Why can’t a women by more like a man?” In the context of clinical care it seems that the song should go “Why can’t a man be more like a woman?

— Richard Lilford, CLAHRC WM Director

References:

  1. Tsugawa Y, Jena AB, Figueroa JF, et al. Comparison of Hospital Mortality and Readmission Rates for Medicare Patients Treated by Male vs Female Physicians. JAMA Intern Med. 2016.

Physician Assistants and Nurse Practitioners go Head-to-Head with Doctors

Mafi and colleagues have used a large primary care database to compare use of guideline-discordant low-value health care services.[1] On multivariate analysis there is no winner – they use this service on an equivalent proportion of index conditions (e.g. use of x-ray in backache). Risk-adjustment and using the indication rather than the patient to create denominators reduces (but of course cannot eliminate) bias. Note, however, that making the same proportion of guideline-discordant services does not mean that care was of equivalent quality, since the services may be better targeted in one group than the other. The results support greater use of less expensive health personnel for the bulk of primary care, so that medical expertise can be better used.

— Richard Lilford, CLAHRC WM Director

References:

  1. Mafi JN, Wee CC, Davis RB, Landon BE. Comparing Use of Low-Value Health Care Services Among U.S. Advanced Practice Clinicians and Physicians. Ann Intern Med. 2016; 165(4): 237-44.

Do we Need ‘Situations’ to Make a Situational Judgement Test?

Rank the following options in order of their likely effectiveness or the extent to which they reflect ideal behaviour in a work situation.

  1. Make a list of the patients under your care on the acute assessment unit, detailing their outstanding issues, leaving this on the doctor’s office notice board when your shift ends and then leave at the end of your shift.
  2. Quickly go around each of the patients on the acute assessment unit, leaving an entry in the notes highlighting the major outstanding issues relating to each patient and then leave at the end of your shift.
  3. Make a list of patients and outstanding investigations to give to your colleague as soon as she arrives.
  4. Ask your registrar if you can leave a list of your patients and their outstanding issues with him to give to your colleague when she arrives and then leave at the end of your shift.
  5. Leave a message for your partner explaining that you will be 30 minutes late.

053 GB - SJT Doctor

How would your ranking change if you knew the following about the situation?

You are just finishing a busy shift on the Acute Assessment Unit (AAU). Your FY1 colleague who is due to replace you for the evening shift leaves a message with the nurse in charge that she will be 15 to 30 minutes late. There is only a 30 minute overlap between your timetables to handover to your colleague. You need to leave on time as you have a social engagement to attend with your partner.

(Example from UKFPO SJT Practice Paper © MSC Assessment 2014, reproduced with permission.)

The use of situational judgement tests (SJTs) for selection into education, training and employment has proliferated in recent years, but there remains an absence of theory to explain why they may be predictive of subsequent performance.[1] The name suggests that the tests are an assessment of a candidate’s ability to make a judgement about the most appropriate action in challenging work-related situations; suggesting that the tests must include descriptions of such challenging work-related situations. But your ranking of the possible actions listed above probably did not change much (if at all) once you knew the exact details of the situation compared to when these had to be deduced from the possible actions listed. A similar finding was recently reported in a fascinating experiment conducted by Krumm and colleagues,[2] with volunteers randomised to complete a teamwork SJT with or without situation descriptions. Those given the situation descriptions scored, on average, just 8.5% higher than those not given the descriptions. Of course, consideration of the need for a situation description is only possible for SJTs in a format where possible actions are presented to candidates (commonly known as multiple choice), but this format is generally used in practice as it facilitates marking and scoring.

Krumm et al.’s findings clearly raise doubts as to the intended construct of the test (i.e. the candidate’s judgement of specific situations); yet SJTs are predictive of workplace performance, with correlations of around 0.30 reported in meta-analyses (see for example McDaniel et al.).[3] So if a SJT doesn’t actually require a “situation” to enable a useful assessment of a candidate’s likely future performance, then what exactly is the assessment of? Lievens and Motowildo [4] suggest that it is of general domain knowledge regarding the utility of expressing certain traits, such as agreeableness, based on the knowledge that such traits help to ensure effective workplace importance. The implication of this theory for practice is that SJTs may not need to be particularly specific and could therefore be shared across professions and geographical boundaries, making them a particularly cost-effective selection tool. The implication for research is that we need more evidence on the antecedents of general domain knowledge, such as family background, both as part of theoretical development and to evaluate the fairness of SJTs for selection.

And what if one does actually desire an assessment of situational judgement as opposed to general domain knowledge, since both have independent predictive validity for job performance? Rockstuhl and colleagues suggest that candidates need to be asked for an explicit, open-ended judgement of the situation (e.g. “what are the thoughts, feelings and ideas of the people in the situation?”) rather than what they think is the most appropriate response to it.[5] The nub here is whether including open-ended assessments to enable measurement of situational judgement is cost-effective given their incremental validity over general domain knowledge and the cost of marking responses (with at least two markers required). For the moment we simply note that a rather large envelope would be required for even a rapid assessment of selection utility!

— Celia Taylor, Senior Lecturer

References:

  1. Campion MC, Ployhart RE, MacKenzie Jr WI. The state of research on situational judgment tests: a content analysis and directions for future research. Hum Perform. 2014; 27(4): 283-310.
  2. Krumm S, Lievens F, Hüffmeier J, et al. How “situational” is judgment in situational judgment tests? J Appl Psychol. 2015; 100(2): 399-416.
  3. McDaniel MA, Hartman NS, Whetzel DL, Grubb III WL. Situational judgment tests, response instructions, and validity: a meta‐analysis. Pers Psychol. 2007; 60(1): 63-91.
  4. Lievens F, & Motowidlo SJ. Situational judgment tests: From measures of situational judgment to measures of general domain knowledge. Ind Organ Psychol. 2016: 9(1): 3-22.
  5. Rockstuhl T, Ang S, Ng KY, Lievens F, Van Dyne L. Putting judging situations into situational judgment tests: Evidence from intercultural multimedia SJTs. J Appl Psychol. 2015; 100(2): 464-80.

How Many Doctors Do We Really Need?

In a previous post we blogged about the changing nature of medical practice: the influences of regulation, guidelines, sub-specialisation, and patient expectations. We mentioned skills substitution, whereby less experienced staff take on tasks previously carried out by doctors. We also mentioned the role of Information Technology, but shied away from discussing the implications for medical manpower. However, it seems important to ask whether Information Technology could reduce the need for medical input by increasing the scope for skill substitution. Some patients have complex needs or vague symptoms, and such patients we assume will need to be seen by someone with deep medical knowledge to underpin professional judgements, and to provide patients with such an informed account of the probable causes of their illness and the risks and benefits of viable options. But much of medicine is rather algorithmic. A patient presents with back pain – follow the guidelines and refer the patient if any ‘red flags’ appear, for example. Many of the criteria for referral and treatment are specified in guidelines. Meanwhile, computers increasingly find abnormal patterns in a patient’s data that the doctor has overlooked. Work in CLAHRC WM shows that many patients do not receive indicated medicines.[1] Health promotion can be delivered by nurse and routine follow-up cases triaged by Physician Assistants. A technician can be trained to perform many surgical operations, such as hernia repair and varicose vein removals, and Physician Assistants already administer anaesthetics safely in many parts of the world.[2] Surely we should re-define medicine to cover the cognitively demanding aspect of care and those where judgements must be made under considerable uncertainty.

In the USA they talk about “people working up to their license”. What they mean is that it is inefficient for people to work for extended periods at cognitive or skill levels well below those they have attained by virtue of their intellect and education. Working way below the level is not only inefficient, but deeply frustrating for the clinician involved, predisposing them to burn out. Use doctors to doctor, not to fill in forms and perform routine surgical operations.

We conclude by suggesting that there is a case for re-engineering medical care or at least articulating a forward vision. The next step is some careful modelling, informed by experts, to map patterns of practice, assign tasks to cognitive categories, and calculate manpower configurations that are both safe and economical. Such a process would likely identify a more specific, cognitively elite role for expensive personnel who have trained for 15 years to obtain their license. In turn, this may suggest that less people of this type will be needed in the future.

While high-income countries should address the question “how much should we reduce the medical workforce, if at all?”, low-income countries face the reciprocal question, “by how much should we increase the medical work-force?” Countries such as Kenya have only two doctors per 10,000 population, compared to 28 in the UK, and 25 in the United States.[3] Much of the shortfall is covered by other cadres, especially medical officers (who work independently), and nurses. Health personnel are strongly buttressed by community health workers, a type of health worker that we have discussed in previous posts.[4] [5] Information Technology is unsurprisingly very under-developed in low-income countries, although telemedicine is increasingly used. It is particularly difficult to attract doctors to work in rural areas, and there is the perennial issue of the medical brain drain. The time is thus propitious to consider carefully the human resource needs not just of high-, but also of low- and middle-income countries, and consider how these may be affected by improving Information Technology infrastructure.

— Richard Lilford, CLAHRC WM Director

Reference:

  1. Wu J, Yao GL, Zhu S, Mohammed MA. Marshall T. Patient factors influencing the prescribing of lipid lowering drugs for primary prevention of cardiovascular disease in UK general practice: a national retrospective cohort study. PLoS One. 2013; 8(7): e67611.
  2. Mullan F & Frehywot S. Non-Physician Clinicians in 47 Sub-Saharan African Countries. Lancet. 2007; 370: 2158-63.
  3. World Health Organization. Health Workforce: Density of Physicians (total number per 1000 population): Latest available year. 2015.
  4. Lilford RJ. Lay Community Health Workers. NIHR CLAHRC West Midlands News Blog. 10 April 2015.
  5. Lilford RJ. An Intervention So Big You Can see it From Space. NIHR CLAHRC West Midlands News Blog. 4 December 2015.

Calling All Doctors. And Lawyers. And Politicians.

The idea of defensive medicine is that ordering lots of tests, admitting patients and making referrals will reduce the risk of being sued, even when there is a low probability that the activity will be beneficial. In obstetrics it is well known that the clinician is much more likely to be sued for not doing, than for doing, a Caesarean section.

But what about general medicine – is it true that defensive medicine works in its own terms, i.e. that it will reduce the risk of medical litigation? Resource use by physicians is a proxy for defensive medicine. So, is there a correlation between physician spending and litigation risk?

STOP AND THINK – WHAT IS YOUR GUESS?

NOW READ ON.

Well, the answer (and it was not what the CLAHRC WM Director guessed) is that there is a strong negative correlation between spending on extra activities and the risk of litigation.[1]

This is a spectacular record linkage study – in this case data from Florida hospitals and data from the Florida Office of Insurance Regulation. Doctors were compared within speciality after risk-adjustment for patient severity. To avoid the possibility of reverse causality, expenditure in one calendar year was correlated with incidence of litigation in the following year, it having been established that expenditure patterns within clinicians are highly correlated across time epochs. The study also replicated the well-known negative correlation between Caesarean section rate and risk of a malpractice claim.

So it’s not just how well you communicate with patients that determines your litigation risk, but how defensive your practice is. Why is this? Do patients get a sense that you have taken the complaint seriously when you have done the things that consume the resources? Or do they sense that their chances of successful litigations are reduced? Or is the extra-expenditure effective in reducing adverse events? The policy implications turn on the mechanisms by which higher expenditure translates to lower claims. For instance, if activity reduces the probability of a misdiagnosis, then defensive practice is not really defensive – it is clinically effective and quite possibly cost-effective because it has the potential to reduce the costs of both adverse events and litigation. On the other hand, if the (negative) correlation is an artefact of patient perception, then education may be the way forward. From the point of view of the clinician, the implications are pretty obvious, whatever the mechanism.

— Richard Lilford, CLAHRC WM Director

Reference:

  1. Jena AB, Schoemaker L, Bhattacharya J, Seabury SA. Physician spending and subsequent risk of malpractice claims: observational study. BMJ. 2015; 351: h5516.

A Book for a Change

The CLAHRC WM Director finds himself on an expert working group established to advise the Secretary of State for Health – Jeremy Hunt – on future strategy for Information Technology in the English NHS. The group is chaired by a famous American Physician and West Coast Professor, Bob Wachter. Word has it that the said Wachter was identified as a candidate to chair the working group on the basis of his recent book – ‘The Digital Doctor’.[1] So the CLAHRC WM Director thought he had better read it. It arrived in the post today and we shall report on it further in due course. But a quick glance at the first few chapters indicate that it is extremely well-written and researched. News Blog readers will know that the CLAHRC WM Director is obsessed with the doctor-patient relationship [2] [3] – the basis for the whole of medical practice. Wachter says that health care was slow to computerise, but there have been recent examples of a rush to make up for lost time on both sides of the Atlantic. And in this haste the precious doctor-patient relationship has been side-lined. Indeed, the possibility that this could happen was studied formally by the CLAHRC WM Director no less than three decades ago.[4] It now appears to be happening on an epic scale. But we can’t go back – like the great white shark, we must keep moving forward to find the best way to use technology. Sometimes paper may be best, as discussed in a previous blog. Anyway, the CLAHRC WM Director shall keep reading and report back to you. In the meantime, consider ordering a copy for yourself.

— Richard Lilford, CLAHRC WM Director

References:

  1. Wachter R. The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age. New York, NY: McGraw-Hill Education. 2015.
  2. Lilford RJ. Two Ideas of what it is to be a Doctor. CLAHRC WM News Blog. 14 August 2015.
  3. Lilford RJ. A Standardised Patient’s Story. CLAHRC WM News Blog. 18 December 2015.
  4. Brownbridge G, Lilford RJ, Tindale-Biscoe S. Use of a computer to take booking histories in a hospital antenatal clinic. Acceptability to midwives and patients and effects on the midwife-patient interaction. Med Care. 1988; 26(5): 474-87.

The CLAHRC WM Director’s Tale

The CLAHRC WM Director waxed lyrical about the deep satisfaction that comes from treating patients at a recent question and answer session at the University of Warwick’s “Festival of the Imagination”. Prof Richard Smith, the ebullient host of the event, gently chided the CLAHRC WM Director on the grounds that he is now a public health doctor and no longer sees patients. Yet the CLAHRC WM Director believed every word he said – how did it come about then, that a dedicated doctor came to give up clinical practice?

The CLAHRC WM Director built up a large referral practice in feto-maternal medicine after assuming the Chair of Obstetrics and Gynaecology in Leeds in 1984. He established the first feto-maternal training centre in the North of England and two brilliant young clinicians, Jim Thornton (now Professor of Obstetrics and Gynaecology in Nottingham) and Gerald Mason (now retired) became his protégés. The CLAHRC WM Director worked hard to ensure that they both became consultants in his hospital. This allowed him to take on other roles. He was elected to the Council of the Royal College, and became chairman of one of its committees; he was on the management committee of the medical school and chairman of the Institute of Epidemiology at the University of Leeds; and he was an executive director of the United Leeds Teaching Hospitals. The upshot of all of this was that Thornton and Mason gradually took over the future CLAHRC WM Director’s carefully nurtured referral practice so that he became increasingly supernumerary. So the poor old CLAHRC WM Director had become a victim of his success. However, he had also been elected to a full membership of the Faculty of Public Health. This meant that he was in a position to apply when head-hunters called to tell him about a job in the newly expanded R&D Department of Health under Sir Michael Peckham.

The rest, as they say, is history. He languished in the civil service for five years and then returned to academia where he has worked happily for the last 15 years. At dinner parties and elsewhere the question most often asked is “Don’t you miss seeing patients?” And his answer is always simple: “Yes”.

— Richard Lilford, CLAHRC WM Director

A Standardised Patient’s Story

The CLAHRC WM Director loves beautifully written articles about the doctor-patient relationship – a beautiful and precious thing that must be defended against all emotionally shallow attempts to downgrade it. The New England Journal of Medicine recently carried a moving story from a Standardised Patient (SP) (‘fake’ patient).[1] She recounts, in a tender way, her interaction with a generation of medical students who she taught and examined, then describes her own severe illness, bone marrow transplant, and recovery, before concluding with an account of her experience of resuming her SP role. May I entice you to read it by closing, for this year, with her closing words, “If I can help aspiring caregivers learn how to reach through the quagmire of dread and pain to help patients get through their most trying times, it will have been worth every awkward encounter and psychosomatic symptom I’ve suffered along the way.”

— Richard Lilford, CLAHRC WM Director

Reference:

  1. Cole EA. My Life as a (Fake) Patient. N Engl J Med. 2015; 373: 2302-3.